Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC

Facility

$36,704.28

Service Code	MSDRG 656
Min. Negotiated Rate	$24,906.47
Max. Negotiated Rate	$36,704.28
Rate for Payer: Anthem Medicaid	$24,906.47
Rate for Payer: Anthem Medicare Advantage/PPO	$26,217.34
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$36,704.28
Rate for Payer: CareSource Just4Me Medicare	$35,393.41
Rate for Payer: Humana KY Medicaid	$24,906.47
Rate for Payer: Humana Medicare Advantage	$26,217.34
Rate for Payer: Kentucky WC Medicaid	$25,155.54
Rate for Payer: Molina Healthcare Benefit Exchange	$31,460.81
Rate for Payer: Molina Healthcare Medicaid	$25,404.60

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$17,318.01

Service Code	MSDRG 658
Min. Negotiated Rate	$11,751.51
Max. Negotiated Rate	$17,318.01
Rate for Payer: Anthem Medicaid	$11,751.51
Rate for Payer: Anthem Medicare Advantage/PPO	$12,370.01
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$17,318.01
Rate for Payer: CareSource Just4Me Medicare	$16,699.51
Rate for Payer: Humana KY Medicaid	$11,751.51
Rate for Payer: Humana Medicare Advantage	$12,370.01
Rate for Payer: Kentucky WC Medicaid	$11,869.02
Rate for Payer: Molina Healthcare Benefit Exchange	$14,844.01
Rate for Payer: Molina Healthcare Medicaid	$11,986.54

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$15,744.61

Service Code	MSDRG 660
Min. Negotiated Rate	$10,683.84
Max. Negotiated Rate	$15,744.61
Rate for Payer: Anthem Medicaid	$10,683.84
Rate for Payer: Anthem Medicare Advantage/PPO	$11,246.15
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$15,744.61
Rate for Payer: CareSource Just4Me Medicare	$15,182.30
Rate for Payer: Humana KY Medicaid	$10,683.84
Rate for Payer: Humana Medicare Advantage	$11,246.15
Rate for Payer: Kentucky WC Medicaid	$10,790.68
Rate for Payer: Molina Healthcare Benefit Exchange	$13,495.38
Rate for Payer: Molina Healthcare Medicaid	$10,897.52

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$30,285.47

Service Code	MSDRG 659
Min. Negotiated Rate	$20,550.86
Max. Negotiated Rate	$30,285.47
Rate for Payer: Anthem Medicaid	$20,550.86
Rate for Payer: Anthem Medicare Advantage/PPO	$21,632.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$30,285.47
Rate for Payer: CareSource Just4Me Medicare	$29,203.85
Rate for Payer: Humana KY Medicaid	$20,550.86
Rate for Payer: Humana Medicare Advantage	$21,632.48
Rate for Payer: Kentucky WC Medicaid	$20,756.36
Rate for Payer: Molina Healthcare Benefit Exchange	$25,958.98
Rate for Payer: Molina Healthcare Medicaid	$20,961.87

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$12,264.41

Service Code	MSDRG 661
Min. Negotiated Rate	$8,322.28
Max. Negotiated Rate	$12,264.41
Rate for Payer: Anthem Medicaid	$8,322.28
Rate for Payer: Anthem Medicare Advantage/PPO	$8,760.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,264.41
Rate for Payer: CareSource Just4Me Medicare	$11,826.39
Rate for Payer: Humana KY Medicaid	$8,322.28
Rate for Payer: Humana Medicare Advantage	$8,760.29
Rate for Payer: Kentucky WC Medicaid	$8,405.50
Rate for Payer: Molina Healthcare Benefit Exchange	$10,512.35
Rate for Payer: Molina Healthcare Medicaid	$8,488.72

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$13,738.35

Service Code	MSDRG 689
Min. Negotiated Rate	$9,322.45
Max. Negotiated Rate	$13,738.35
Rate for Payer: Anthem Medicaid	$9,322.45
Rate for Payer: Anthem Medicare Advantage/PPO	$9,813.11
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,738.35
Rate for Payer: CareSource Just4Me Medicare	$13,247.70
Rate for Payer: Humana KY Medicaid	$9,322.45
Rate for Payer: Humana Medicare Advantage	$9,813.11
Rate for Payer: Kentucky WC Medicaid	$9,415.68
Rate for Payer: Molina Healthcare Benefit Exchange	$11,775.73
Rate for Payer: Molina Healthcare Medicaid	$9,508.90

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$9,439.29

Service Code	MSDRG 690
Min. Negotiated Rate	$6,405.23
Max. Negotiated Rate	$9,439.29
Rate for Payer: Anthem Medicaid	$6,405.23
Rate for Payer: Anthem Medicare Advantage/PPO	$6,742.35
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,439.29
Rate for Payer: CareSource Just4Me Medicare	$9,102.17
Rate for Payer: Humana KY Medicaid	$6,405.23
Rate for Payer: Humana Medicare Advantage	$6,742.35
Rate for Payer: Kentucky WC Medicaid	$6,469.28
Rate for Payer: Molina Healthcare Benefit Exchange	$8,090.82
Rate for Payer: Molina Healthcare Medicaid	$6,533.34

KIDNEY AND URINARY TRACT NEOPLASMS WITH CC

Facility

$12,228.15

Service Code	MSDRG 687
Min. Negotiated Rate	$8,297.67
Max. Negotiated Rate	$12,228.15
Rate for Payer: Anthem Medicaid	$8,297.67
Rate for Payer: Anthem Medicare Advantage/PPO	$8,734.39
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,228.15
Rate for Payer: CareSource Just4Me Medicare	$11,791.43
Rate for Payer: Humana KY Medicaid	$8,297.67
Rate for Payer: Humana Medicare Advantage	$8,734.39
Rate for Payer: Kentucky WC Medicaid	$8,380.65
Rate for Payer: Molina Healthcare Benefit Exchange	$10,481.27
Rate for Payer: Molina Healthcare Medicaid	$8,463.62

KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC

Facility

$21,517.68

Service Code	MSDRG 686
Min. Negotiated Rate	$14,601.28
Max. Negotiated Rate	$21,517.68
Rate for Payer: Anthem Medicaid	$14,601.28
Rate for Payer: Anthem Medicare Advantage/PPO	$15,369.77
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$21,517.68
Rate for Payer: CareSource Just4Me Medicare	$20,749.19
Rate for Payer: Humana KY Medicaid	$14,601.28
Rate for Payer: Humana Medicare Advantage	$15,369.77
Rate for Payer: Kentucky WC Medicaid	$14,747.29
Rate for Payer: Molina Healthcare Benefit Exchange	$18,443.72
Rate for Payer: Molina Healthcare Medicaid	$14,893.31

KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC

Facility

$9,135.13

Service Code	MSDRG 688
Min. Negotiated Rate	$6,198.84
Max. Negotiated Rate	$9,135.13
Rate for Payer: Anthem Medicaid	$6,198.84
Rate for Payer: Anthem Medicare Advantage/PPO	$6,525.09
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,135.13
Rate for Payer: CareSource Just4Me Medicare	$8,808.87
Rate for Payer: Humana KY Medicaid	$6,198.84
Rate for Payer: Humana Medicare Advantage	$6,525.09
Rate for Payer: Kentucky WC Medicaid	$6,260.82
Rate for Payer: Molina Healthcare Benefit Exchange	$7,830.11
Rate for Payer: Molina Healthcare Medicaid	$6,322.81

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC

Facility

$13,991.05

Service Code	MSDRG 695
Min. Negotiated Rate	$9,493.93
Max. Negotiated Rate	$13,991.05
Rate for Payer: Anthem Medicaid	$9,493.93
Rate for Payer: Anthem Medicare Advantage/PPO	$9,993.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,991.05
Rate for Payer: CareSource Just4Me Medicare	$13,491.37
Rate for Payer: Humana KY Medicaid	$9,493.93
Rate for Payer: Humana Medicare Advantage	$9,993.61
Rate for Payer: Kentucky WC Medicaid	$9,588.87
Rate for Payer: Molina Healthcare Benefit Exchange	$11,992.33
Rate for Payer: Molina Healthcare Medicaid	$9,683.81

KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$8,096.31

Service Code	MSDRG 696
Min. Negotiated Rate	$5,493.93
Max. Negotiated Rate	$8,096.31
Rate for Payer: Anthem Medicaid	$5,493.93
Rate for Payer: Anthem Medicare Advantage/PPO	$5,783.08
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,096.31
Rate for Payer: CareSource Just4Me Medicare	$7,807.16
Rate for Payer: Humana KY Medicaid	$5,493.93
Rate for Payer: Humana Medicare Advantage	$5,783.08
Rate for Payer: Kentucky WC Medicaid	$5,548.87
Rate for Payer: Molina Healthcare Benefit Exchange	$6,939.70
Rate for Payer: Molina Healthcare Medicaid	$5,603.80

KIDNEY TRANSPLANT

Facility

$35,146.10

Service Code	MSDRG 652
Min. Negotiated Rate	$23,849.14
Max. Negotiated Rate	$35,146.10
Rate for Payer: Anthem Medicaid	$23,849.14
Rate for Payer: Anthem Medicare Advantage/PPO	$25,104.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$35,146.10
Rate for Payer: CareSource Just4Me Medicare	$33,890.89
Rate for Payer: Humana KY Medicaid	$23,849.14
Rate for Payer: Humana Medicare Advantage	$25,104.36
Rate for Payer: Kentucky WC Medicaid	$24,087.63
Rate for Payer: Molina Healthcare Benefit Exchange	$30,125.23
Rate for Payer: Molina Healthcare Medicaid	$24,326.12

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC

Facility

$52,612.69

Service Code	MSDRG 650
Min. Negotiated Rate	$35,701.47
Max. Negotiated Rate	$52,612.69
Rate for Payer: Anthem Medicaid	$35,701.47
Rate for Payer: Anthem Medicare Advantage/PPO	$37,580.49
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$52,612.69
Rate for Payer: CareSource Just4Me Medicare	$50,733.66
Rate for Payer: Humana KY Medicaid	$35,701.47
Rate for Payer: Humana Medicare Advantage	$37,580.49
Rate for Payer: Kentucky WC Medicaid	$36,058.48
Rate for Payer: Molina Healthcare Benefit Exchange	$45,096.59
Rate for Payer: Molina Healthcare Medicaid	$36,415.49

KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC

Facility

$40,457.09

Service Code	MSDRG 651
Min. Negotiated Rate	$27,453.02
Max. Negotiated Rate	$40,457.09
Rate for Payer: Anthem Medicaid	$27,453.02
Rate for Payer: Anthem Medicare Advantage/PPO	$28,897.92
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$40,457.09
Rate for Payer: CareSource Just4Me Medicare	$39,012.19
Rate for Payer: Humana KY Medicaid	$27,453.02
Rate for Payer: Humana Medicare Advantage	$28,897.92
Rate for Payer: Kentucky WC Medicaid	$27,727.55
Rate for Payer: Molina Healthcare Benefit Exchange	$34,677.50
Rate for Payer: Molina Healthcare Medicaid	$28,002.08

KIMYRSA 10mg (1,200mg SDV)

Facility

$29,086.00

Service Code	HCPCS J2406
Hospital Charge Code	25004312
Hospital Revenue Code	636
Min. Negotiated Rate	$40.92
Max. Negotiated Rate	$27,922.56
Rate for Payer: Aetna Commercial	$22,396.22
Rate for Payer: Anthem Medicaid	$10,002.68
Rate for Payer: Anthem Medicare Advantage/PPO	$40.92
Rate for Payer: Anthem POS/PPO/Traditional	$22,687.08
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$57.28
Rate for Payer: CareSource Just4Me Medicare	$55.24
Rate for Payer: Cash Price	$14,543.00
Rate for Payer: Cash Price	$14,543.00
Rate for Payer: Cigna Commercial	$24,141.38
Rate for Payer: First Health Commercial	$27,631.70
Rate for Payer: Humana Commercial	$24,723.10
Rate for Payer: Humana KY Medicaid	$10,002.68
Rate for Payer: Humana Medicare Advantage	$40.92
Rate for Payer: Kentucky WC Medicaid	$10,104.48
Rate for Payer: Medical Mutual Of Ohio HMO	$23,850.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$21,465.47
Rate for Payer: Molina Healthcare Benefit Exchange	$49.10
Rate for Payer: Molina Healthcare Medicaid	$10,203.37
Rate for Payer: Ohio Health Choice Commercial	$25,595.68
Rate for Payer: Ohio Health Group HMO	$21,814.50
Rate for Payer: Ohio Health Group PPO Differential	$5,817.20
Rate for Payer: Ohio Health Group PPO No Differential	$3,781.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$9,016.66
Rate for Payer: PHCS Commercial	$27,922.56
Rate for Payer: United Healthcare All Payer	$25,595.68

KIMYRSA 10mg (1,200mg SDV)

Facility

$29,086.00

Service Code	HCPCS J2406
Hospital Charge Code	25004312
Hospital Revenue Code	636
Min. Negotiated Rate	$3,781.18
Max. Negotiated Rate	$27,922.56
Rate for Payer: Aetna Commercial	$22,396.22
Rate for Payer: Anthem POS/PPO/Traditional	$22,687.08
Rate for Payer: Cash Price	$14,543.00
Rate for Payer: Cigna Commercial	$24,141.38
Rate for Payer: First Health Commercial	$27,631.70
Rate for Payer: Humana Commercial	$24,723.10
Rate for Payer: Medical Mutual Of Ohio HMO	$23,850.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$21,465.47
Rate for Payer: Molina Healthcare Benefit Exchange	$8,725.80
Rate for Payer: Ohio Health Choice Commercial	$25,595.68
Rate for Payer: Ohio Health Group HMO	$21,814.50
Rate for Payer: Ohio Health Group PPO Differential	$5,817.20
Rate for Payer: Ohio Health Group PPO No Differential	$3,781.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$9,016.66
Rate for Payer: PHCS Commercial	$27,922.56
Rate for Payer: United Healthcare All Payer	$25,595.68

KINEVAC (SINCALIDE) 5 MCG INJ

Facility

$558.46

Service Code	HCPCS J2805
Hospital Charge Code	25002356
Hospital Revenue Code	636
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$536.12
Rate for Payer: Aetna Commercial	$430.01
Rate for Payer: Anthem POS/PPO/Traditional	$435.60
Rate for Payer: Cash Price	$279.23
Rate for Payer: Cigna Commercial	$463.52
Rate for Payer: First Health Commercial	$530.54
Rate for Payer: Humana Commercial	$474.69
Rate for Payer: Medical Mutual Of Ohio HMO	$457.94
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$412.14
Rate for Payer: Molina Healthcare Benefit Exchange	$167.54
Rate for Payer: Ohio Health Choice Commercial	$491.44
Rate for Payer: Ohio Health Group HMO	$418.84
Rate for Payer: Ohio Health Group PPO Differential	$111.69
Rate for Payer: Ohio Health Group PPO No Differential	$72.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$173.12
Rate for Payer: PHCS Commercial	$536.12
Rate for Payer: United Healthcare All Payer	$491.44

KINEVAC (SINCALIDE) 5 MCG INJ

Facility

$558.46

Service Code	HCPCS J2805
Hospital Charge Code	25002356
Hospital Revenue Code	636
Min. Negotiated Rate	$72.60
Max. Negotiated Rate	$536.12
Rate for Payer: Aetna Commercial	$430.01
Rate for Payer: Anthem Medicaid	$192.05
Rate for Payer: Anthem POS/PPO/Traditional	$435.60
Rate for Payer: Cash Price	$279.23
Rate for Payer: Cigna Commercial	$463.52
Rate for Payer: First Health Commercial	$530.54
Rate for Payer: Humana Commercial	$474.69
Rate for Payer: Humana KY Medicaid	$192.05
Rate for Payer: Kentucky WC Medicaid	$194.01
Rate for Payer: Medical Mutual Of Ohio HMO	$457.94
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$412.14
Rate for Payer: Molina Healthcare Benefit Exchange	$167.54
Rate for Payer: Molina Healthcare Medicaid	$195.91
Rate for Payer: Ohio Health Choice Commercial	$491.44
Rate for Payer: Ohio Health Group HMO	$418.84
Rate for Payer: Ohio Health Group PPO Differential	$111.69
Rate for Payer: Ohio Health Group PPO No Differential	$72.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$173.12
Rate for Payer: PHCS Commercial	$536.12
Rate for Payer: United Healthcare All Payer	$491.44

KIT ASCITE SHUNT PERC ACC 15.5

Facility

$18,057.98

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,347.54
Max. Negotiated Rate	$17,335.66
Rate for Payer: Aetna Commercial	$13,904.64
Rate for Payer: Anthem POS/PPO/Traditional	$14,085.22
Rate for Payer: Cash Price	$9,028.99
Rate for Payer: Cigna Commercial	$14,988.12
Rate for Payer: First Health Commercial	$17,155.08
Rate for Payer: Humana Commercial	$15,349.28
Rate for Payer: Medical Mutual Of Ohio HMO	$14,807.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$13,326.79
Rate for Payer: Molina Healthcare Benefit Exchange	$5,417.39
Rate for Payer: Ohio Health Choice Commercial	$15,891.02
Rate for Payer: Ohio Health Group HMO	$13,543.48
Rate for Payer: Ohio Health Group PPO Differential	$3,611.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,347.54
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,597.97
Rate for Payer: PHCS Commercial	$17,335.66
Rate for Payer: United Healthcare All Payer	$15,891.02

KIT ASCITE SHUNT PERC ACC 15.5

Facility

$18,057.98

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,347.54
Max. Negotiated Rate	$17,335.66
Rate for Payer: Aetna Commercial	$13,904.64
Rate for Payer: Anthem Medicaid	$6,210.14
Rate for Payer: Anthem POS/PPO/Traditional	$14,085.22
Rate for Payer: Cash Price	$9,028.99
Rate for Payer: Cigna Commercial	$14,988.12
Rate for Payer: First Health Commercial	$17,155.08
Rate for Payer: Humana Commercial	$15,349.28
Rate for Payer: Humana KY Medicaid	$6,210.14
Rate for Payer: Kentucky WC Medicaid	$6,273.34
Rate for Payer: Medical Mutual Of Ohio HMO	$14,807.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$13,326.79
Rate for Payer: Molina Healthcare Benefit Exchange	$5,417.39
Rate for Payer: Molina Healthcare Medicaid	$6,334.74
Rate for Payer: Ohio Health Choice Commercial	$15,891.02
Rate for Payer: Ohio Health Group HMO	$13,543.48
Rate for Payer: Ohio Health Group PPO Differential	$3,611.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,347.54
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,597.97
Rate for Payer: PHCS Commercial	$17,335.66
Rate for Payer: United Healthcare All Payer	$15,891.02

KIT BIO PREP BONE

Facility

$1,730.39

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$224.95
Max. Negotiated Rate	$1,661.17
Rate for Payer: Aetna Commercial	$1,332.40
Rate for Payer: Anthem Medicaid	$595.08
Rate for Payer: Anthem POS/PPO/Traditional	$1,349.70
Rate for Payer: Cash Price	$865.20
Rate for Payer: Cigna Commercial	$1,436.22
Rate for Payer: First Health Commercial	$1,643.87
Rate for Payer: Humana Commercial	$1,470.83
Rate for Payer: Humana KY Medicaid	$595.08
Rate for Payer: Kentucky WC Medicaid	$601.14
Rate for Payer: Medical Mutual Of Ohio HMO	$1,418.92
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,277.03
Rate for Payer: Molina Healthcare Benefit Exchange	$519.12
Rate for Payer: Molina Healthcare Medicaid	$607.02
Rate for Payer: Ohio Health Choice Commercial	$1,522.74
Rate for Payer: Ohio Health Group HMO	$1,297.79
Rate for Payer: Ohio Health Group PPO Differential	$346.08
Rate for Payer: Ohio Health Group PPO No Differential	$224.95
Rate for Payer: Ohio Health Group PPO SOMC Employees	$536.42
Rate for Payer: PHCS Commercial	$1,661.17
Rate for Payer: United Healthcare All Payer	$1,522.74

KIT BIO PREP BONE

Facility

$1,730.39

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$224.95
Max. Negotiated Rate	$1,661.17
Rate for Payer: Aetna Commercial	$1,332.40
Rate for Payer: Anthem POS/PPO/Traditional	$1,349.70
Rate for Payer: Cash Price	$865.20
Rate for Payer: Cigna Commercial	$1,436.22
Rate for Payer: First Health Commercial	$1,643.87
Rate for Payer: Humana Commercial	$1,470.83
Rate for Payer: Medical Mutual Of Ohio HMO	$1,418.92
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,277.03
Rate for Payer: Molina Healthcare Benefit Exchange	$519.12
Rate for Payer: Ohio Health Choice Commercial	$1,522.74
Rate for Payer: Ohio Health Group HMO	$1,297.79
Rate for Payer: Ohio Health Group PPO Differential	$346.08
Rate for Payer: Ohio Health Group PPO No Differential	$224.95
Rate for Payer: Ohio Health Group PPO SOMC Employees	$536.42
Rate for Payer: PHCS Commercial	$1,661.17
Rate for Payer: United Healthcare All Payer	$1,522.74

KIT BIOPRO IMPLANT

Facility

$8,275.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,075.75
Max. Negotiated Rate	$7,944.00
Rate for Payer: Aetna Commercial	$6,371.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,454.50
Rate for Payer: Cash Price	$4,137.50
Rate for Payer: Cigna Commercial	$6,868.25
Rate for Payer: First Health Commercial	$7,861.25
Rate for Payer: Humana Commercial	$7,033.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,785.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,106.95
Rate for Payer: Molina Healthcare Benefit Exchange	$2,482.50
Rate for Payer: Ohio Health Choice Commercial	$7,282.00
Rate for Payer: Ohio Health Group HMO	$6,206.25
Rate for Payer: Ohio Health Group PPO Differential	$1,655.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,075.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,565.25
Rate for Payer: PHCS Commercial	$7,944.00
Rate for Payer: United Healthcare All Payer	$7,282.00

KIT BIOPRO IMPLANT

Facility

$8,275.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,075.75
Max. Negotiated Rate	$7,944.00
Rate for Payer: Aetna Commercial	$6,371.75
Rate for Payer: Anthem Medicaid	$2,845.77
Rate for Payer: Anthem POS/PPO/Traditional	$6,454.50
Rate for Payer: Cash Price	$4,137.50
Rate for Payer: Cigna Commercial	$6,868.25
Rate for Payer: First Health Commercial	$7,861.25
Rate for Payer: Humana Commercial	$7,033.75
Rate for Payer: Humana KY Medicaid	$2,845.77
Rate for Payer: Kentucky WC Medicaid	$2,874.74
Rate for Payer: Medical Mutual Of Ohio HMO	$6,785.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,106.95
Rate for Payer: Molina Healthcare Benefit Exchange	$2,482.50
Rate for Payer: Molina Healthcare Medicaid	$2,902.87
Rate for Payer: Ohio Health Choice Commercial	$7,282.00
Rate for Payer: Ohio Health Group HMO	$6,206.25
Rate for Payer: Ohio Health Group PPO Differential	$1,655.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,075.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,565.25
Rate for Payer: PHCS Commercial	$7,944.00
Rate for Payer: United Healthcare All Payer	$7,282.00

Know your out-of-pocket cost for care.

All Charges