Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ANESTH UPPER LEG SURGERY

Professional

Both

$8.00

Service Code	HCPCS 1250
Hospital Charge Code	37000103
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPER LEG SURGERY

Facility

$8.00

Service Code	HCPCS 01250
Hospital Charge Code	37000103
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPER LEG SURGERY

Facility

$8.00

Service Code	HCPCS 01250
Hospital Charge Code	37000103
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPER LEG VEINS SURG

Facility

$8.00

Service Code	HCPCS 01260
Hospital Charge Code	37000104
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPER LEG VEINS SURG

Facility

$8.00

Service Code	HCPCS 01260
Hospital Charge Code	37000104
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPER LEG VEINS SURG

Professional

Both

$8.00

Service Code	HCPCS 1260
Hospital Charge Code	37000104
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPR ARM ARTERY SURG

Facility

$8.00

Service Code	HCPCS 01770
Hospital Charge Code	37000147
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM ARTERY SURG

Professional

Both

$8.00

Service Code	HCPCS 1770
Hospital Charge Code	37000147
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPR ARM ARTERY SURG

Facility

$8.00

Service Code	HCPCS 01770
Hospital Charge Code	37000147
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM EMBOLECTOMY

Professional

Both

$8.00

Service Code	HCPCS 1772
Hospital Charge Code	37000148
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPR ARM EMBOLECTOMY

Facility

$8.00

Service Code	HCPCS 01772
Hospital Charge Code	37000148
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM EMBOLECTOMY

Facility

$8.00

Service Code	HCPCS 01772
Hospital Charge Code	37000148
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM PROCEDURE

Professional

Both

$8.00

Service Code	HCPCS 1730
Hospital Charge Code	37000141
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPR ARM PROCEDURE

Facility

$8.00

Service Code	HCPCS 01730
Hospital Charge Code	37000141
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM PROCEDURE

Facility

$8.00

Service Code	HCPCS 01730
Hospital Charge Code	37000141
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM TENDON SURG

Facility

$8.00

Service Code	HCPCS 01712
Hospital Charge Code	37000139
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM TENDON SURG

Professional

Both

$4.20

Service Code	HCPCS 1714
Hospital Charge Code	37000268
Hospital Revenue Code	370
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.94
Rate for Payer: Cash Price	$2.10
Rate for Payer: Multiplan PHCS	$2.52
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2.94
Rate for Payer: UHCCP Medicaid	$1.47

ANESTH UPPR ARM TENDON SURG

Facility

$8.00

Service Code	HCPCS 01712
Hospital Charge Code	37000139
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM TENDON SURG

Professional

Both

$8.00

Service Code	HCPCS 1712
Hospital Charge Code	37000139
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH UPPR ARM VEIN REPAIR

Facility

$8.00

Service Code	HCPCS 01782
Hospital Charge Code	37000150
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM VEIN REPAIR

Facility

$8.00

Service Code	HCPCS 01782
Hospital Charge Code	37000150
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH UPPR ARM VEIN REPAIR

Professional

Both

$8.00

Service Code	HCPCS 1782
Hospital Charge Code	37000150
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH VAGINAL DELIVERY ONLY

Facility

$8.00

Service Code	HCPCS 01960
Hospital Charge Code	37000165
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

ANESTH VAGINAL DELIVERY ONLY

Professional

Both

$8.00

Service Code	HCPCS 1960
Hospital Charge Code	37000165
Hospital Revenue Code	370
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$4.00
Rate for Payer: Multiplan PHCS	$4.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5.60
Rate for Payer: UHCCP Medicaid	$2.80

ANESTH VAGINAL DELIVERY ONLY

Facility

$8.00

Service Code	HCPCS 01960
Hospital Charge Code	37000165
Hospital Revenue Code	370
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$7.68
Rate for Payer: Aetna Commercial	$6.16
Rate for Payer: Anthem Medicaid	$2.75
Rate for Payer: Anthem POS/PPO/Traditional	$6.24
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna Commercial	$6.64
Rate for Payer: First Health Commercial	$7.60
Rate for Payer: Humana Commercial	$6.80
Rate for Payer: Humana KY Medicaid	$2.75
Rate for Payer: Kentucky WC Medicaid	$2.78
Rate for Payer: Medical Mutual Of Ohio HMO	$6.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2.40
Rate for Payer: Molina Healthcare Medicaid	$2.81
Rate for Payer: Ohio Health Choice Commercial	$7.04
Rate for Payer: Ohio Health Group HMO	$6.00
Rate for Payer: Ohio Health Group PPO Differential	$6.40
Rate for Payer: Ohio Health Group PPO No Differential	$6.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5.52
Rate for Payer: PHCS Commercial	$7.68
Rate for Payer: United Healthcare All Payer	$7.04

Know your out-of-pocket cost for care.

All Charges