Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

LAPAROSCOPIC REV OF COLOSTOMY

Professional

Both

$1,220.00

Service Code	HCPCS 44238
Hospital Charge Code	76102768
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2,527.03
Rate for Payer: Buckeye Medicare Advantage	$1,220.00
Rate for Payer: Cash Price	$610.00
Rate for Payer: Cash Price	$610.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$2,527.03
Rate for Payer: Multiplan PHCS	$732.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$854.00
Rate for Payer: UHCCP Medicaid	$427.00

LAPAROSCOPIC SALPINGECTOMY

Professional

Both

$1,800.00

Service Code	HCPCS 58679
Hospital Charge Code	76102254
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,800.00
Rate for Payer: Buckeye Medicare Advantage	$1,800.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,260.00
Rate for Payer: UHCCP Medicaid	$630.00

LAPAROSCOPIC SALPINGECTOMY

Facility

$1,800.00

Service Code	HCPCS 58679
Hospital Charge Code	76102254
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem Medicaid	$619.02
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$1,494.00
Rate for Payer: First Health Commercial	$1,710.00
Rate for Payer: Humana Commercial	$1,530.00
Rate for Payer: Humana KY Medicaid	$619.02
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$625.32
Rate for Payer: Medical Mutual Of Ohio HMO	$1,476.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,328.40
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$631.44
Rate for Payer: Ohio Health Choice Commercial	$1,584.00
Rate for Payer: Ohio Health Group HMO	$1,350.00
Rate for Payer: Ohio Health Group PPO Differential	$360.00
Rate for Payer: Ohio Health Group PPO No Differential	$234.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$558.00
Rate for Payer: PHCS Commercial	$1,728.00
Rate for Payer: United Healthcare All Payer	$1,584.00

LAPAROSCOPIC SALPINGECTOMY

Facility

$1,800.00

Service Code	HCPCS 58679
Hospital Charge Code	76102254
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$1,728.00
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$1,494.00
Rate for Payer: First Health Commercial	$1,710.00
Rate for Payer: Humana Commercial	$1,530.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,476.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,328.40
Rate for Payer: Molina Healthcare Benefit Exchange	$540.00
Rate for Payer: Ohio Health Choice Commercial	$1,584.00
Rate for Payer: Ohio Health Group HMO	$1,350.00
Rate for Payer: Ohio Health Group PPO Differential	$360.00
Rate for Payer: Ohio Health Group PPO No Differential	$234.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$558.00
Rate for Payer: PHCS Commercial	$1,728.00
Rate for Payer: United Healthcare All Payer	$1,584.00

LAPAROSCOPIC SALPINGECTOMY(P

Professional

Both

$1,800.00

Service Code	HCPCS 58679
Hospital Charge Code	761P2254
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,800.00
Rate for Payer: Buckeye Medicare Advantage	$1,800.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,260.00
Rate for Payer: UHCCP Medicaid	$630.00

LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY

Facility

$6,985.45

Service Code	CPT 59150
Hospital Revenue Code	360
Min. Negotiated Rate	$4,989.61
Max. Negotiated Rate	$6,985.45
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53

LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY

Facility

$6,985.45

Service Code	CPT 59151
Hospital Revenue Code	360
Min. Negotiated Rate	$4,989.61
Max. Negotiated Rate	$6,985.45
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53

LAPAROSCOP LYSIS OMENTAL ADHES

Professional

Both

$2,200.00

Service Code	HCPCS 49329
Hospital Charge Code	76102920
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2,200.00
Rate for Payer: Buckeye Medicare Advantage	$2,200.00
Rate for Payer: Cash Price	$1,100.00
Rate for Payer: Cash Price	$1,100.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,320.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,540.00
Rate for Payer: UHCCP Medicaid	$770.00

LAPAROSCOP LYSIS OMENTAL ADHES

Facility

$2,200.00

Service Code	HCPCS 49329
Hospital Charge Code	76102920
Hospital Revenue Code	761
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$1,694.00
Rate for Payer: Anthem Medicaid	$756.58
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$1,716.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Cash Price	$1,100.00
Rate for Payer: Cash Price	$1,100.00
Rate for Payer: Cigna Commercial	$1,826.00
Rate for Payer: First Health Commercial	$2,090.00
Rate for Payer: Humana Commercial	$1,870.00
Rate for Payer: Humana KY Medicaid	$756.58
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$764.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,804.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,623.60
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$771.76
Rate for Payer: Ohio Health Choice Commercial	$1,936.00
Rate for Payer: Ohio Health Group HMO	$1,650.00
Rate for Payer: Ohio Health Group PPO Differential	$440.00
Rate for Payer: Ohio Health Group PPO No Differential	$286.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$682.00
Rate for Payer: PHCS Commercial	$2,112.00
Rate for Payer: United Healthcare All Payer	$1,936.00

LAPAROSCOP LYSIS OMENTAL ADHES

Facility

$2,695.00

Service Code	HCPCS 51999
Hospital Charge Code	76102911
Hospital Revenue Code	761
Min. Negotiated Rate	$350.35
Max. Negotiated Rate	$2,587.20
Rate for Payer: Aetna Commercial	$2,075.15
Rate for Payer: Anthem POS/PPO/Traditional	$2,102.10
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$2,236.85
Rate for Payer: First Health Commercial	$2,560.25
Rate for Payer: Humana Commercial	$2,290.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,209.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,988.91
Rate for Payer: Molina Healthcare Benefit Exchange	$808.50
Rate for Payer: Ohio Health Choice Commercial	$2,371.60
Rate for Payer: Ohio Health Group HMO	$2,021.25
Rate for Payer: Ohio Health Group PPO Differential	$539.00
Rate for Payer: Ohio Health Group PPO No Differential	$350.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$835.45
Rate for Payer: PHCS Commercial	$2,587.20
Rate for Payer: United Healthcare All Payer	$2,371.60

LAPAROSCOP LYSIS OMENTAL ADHES

Professional

Both

$2,695.00

Service Code	HCPCS 51999
Hospital Charge Code	76102911
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2,695.00
Rate for Payer: Buckeye Medicare Advantage	$2,695.00
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,617.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,886.50
Rate for Payer: UHCCP Medicaid	$943.25

LAPAROSCOP LYSIS OMENTAL ADHES

Facility

$2,695.00

Service Code	HCPCS 51999
Hospital Charge Code	76102911
Hospital Revenue Code	761
Min. Negotiated Rate	$350.35
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$2,075.15
Rate for Payer: Anthem Medicaid	$926.81
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$2,102.10
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$2,236.85
Rate for Payer: First Health Commercial	$2,560.25
Rate for Payer: Humana Commercial	$2,290.75
Rate for Payer: Humana KY Medicaid	$926.81
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$936.24
Rate for Payer: Medical Mutual Of Ohio HMO	$2,209.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,988.91
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$945.41
Rate for Payer: Ohio Health Choice Commercial	$2,371.60
Rate for Payer: Ohio Health Group HMO	$2,021.25
Rate for Payer: Ohio Health Group PPO Differential	$539.00
Rate for Payer: Ohio Health Group PPO No Differential	$350.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$835.45
Rate for Payer: PHCS Commercial	$2,587.20
Rate for Payer: United Healthcare All Payer	$2,371.60

LAPAROSCOP LYSIS OMENTAL ADHES

Facility

$2,200.00

Service Code	HCPCS 49329
Hospital Charge Code	76102920
Hospital Revenue Code	761
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$2,112.00
Rate for Payer: Aetna Commercial	$1,694.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,716.00
Rate for Payer: Cash Price	$1,100.00
Rate for Payer: Cigna Commercial	$1,826.00
Rate for Payer: First Health Commercial	$2,090.00
Rate for Payer: Humana Commercial	$1,870.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,804.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,623.60
Rate for Payer: Molina Healthcare Benefit Exchange	$660.00
Rate for Payer: Ohio Health Choice Commercial	$1,936.00
Rate for Payer: Ohio Health Group HMO	$1,650.00
Rate for Payer: Ohio Health Group PPO Differential	$440.00
Rate for Payer: Ohio Health Group PPO No Differential	$286.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$682.00
Rate for Payer: PHCS Commercial	$2,112.00
Rate for Payer: United Healthcare All Payer	$1,936.00

LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

Facility

$6,985.45

Service Code	CPT 49320
Hospital Revenue Code	360
Min. Negotiated Rate	$4,989.61
Max. Negotiated Rate	$6,985.45
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53

LAPAROSCOPY ADRENALECTOMY

Facility

$1,410.00

Service Code	HCPCS 60650
Hospital Charge Code	76102282
Hospital Revenue Code	761
Min. Negotiated Rate	$183.30
Max. Negotiated Rate	$1,353.60
Rate for Payer: Aetna Commercial	$1,085.70
Rate for Payer: Anthem POS/PPO/Traditional	$1,099.80
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cigna Commercial	$1,170.30
Rate for Payer: First Health Commercial	$1,339.50
Rate for Payer: Humana Commercial	$1,198.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,156.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,040.58
Rate for Payer: Molina Healthcare Benefit Exchange	$423.00
Rate for Payer: Ohio Health Choice Commercial	$1,240.80
Rate for Payer: Ohio Health Group HMO	$1,057.50
Rate for Payer: Ohio Health Group PPO Differential	$282.00
Rate for Payer: Ohio Health Group PPO No Differential	$183.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$437.10
Rate for Payer: PHCS Commercial	$1,353.60
Rate for Payer: United Healthcare All Payer	$1,240.80

LAPAROSCOPY ADRENALECTOMY

Professional

Both

$1,410.00

Service Code	HCPCS 60650
Hospital Charge Code	76102282
Hospital Revenue Code	761
Min. Negotiated Rate	$493.50
Max. Negotiated Rate	$1,803.56
Rate for Payer: Aetna Commercial	$1,803.56
Rate for Payer: Anthem Medicaid	$739.73
Rate for Payer: Buckeye Medicare Advantage	$1,410.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cigna Commercial	$1,668.31
Rate for Payer: Healthspan PPO	$1,520.98
Rate for Payer: Humana Medicaid	$739.73
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,543.87
Rate for Payer: Molina Healthcare CHIP/Medicaid	$754.52
Rate for Payer: Molina Healthcare Passport	$739.73
Rate for Payer: Multiplan PHCS	$846.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$987.00
Rate for Payer: UHCCP Medicaid	$493.50
Rate for Payer: Wellcare CHIP/Medicaid	$747.13

LAPAROSCOPY ADRENALECTOMY

Facility

$1,410.00

Service Code	HCPCS 60650
Hospital Charge Code	76102282
Hospital Revenue Code	761
Min. Negotiated Rate	$183.30
Max. Negotiated Rate	$1,353.60
Rate for Payer: Aetna Commercial	$1,085.70
Rate for Payer: Anthem Medicaid	$484.90
Rate for Payer: Anthem POS/PPO/Traditional	$1,099.80
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cigna Commercial	$1,170.30
Rate for Payer: First Health Commercial	$1,339.50
Rate for Payer: Humana Commercial	$1,198.50
Rate for Payer: Humana KY Medicaid	$484.90
Rate for Payer: Kentucky WC Medicaid	$489.83
Rate for Payer: Medical Mutual Of Ohio HMO	$1,156.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,040.58
Rate for Payer: Molina Healthcare Benefit Exchange	$423.00
Rate for Payer: Molina Healthcare Medicaid	$494.63
Rate for Payer: Ohio Health Choice Commercial	$1,240.80
Rate for Payer: Ohio Health Group HMO	$1,057.50
Rate for Payer: Ohio Health Group PPO Differential	$282.00
Rate for Payer: Ohio Health Group PPO No Differential	$183.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$437.10
Rate for Payer: PHCS Commercial	$1,353.60
Rate for Payer: United Healthcare All Payer	$1,240.80

LAPAROSCOPY ADRENALECTOMY(P

Professional

Both

$1,410.00

Service Code	HCPCS 60650
Hospital Charge Code	761P2282
Hospital Revenue Code	761
Min. Negotiated Rate	$493.50
Max. Negotiated Rate	$1,803.56
Rate for Payer: Aetna Commercial	$1,803.56
Rate for Payer: Anthem Medicaid	$739.73
Rate for Payer: Buckeye Medicare Advantage	$1,410.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cigna Commercial	$1,668.31
Rate for Payer: Healthspan PPO	$1,520.98
Rate for Payer: Humana Medicaid	$739.73
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,543.87
Rate for Payer: Molina Healthcare CHIP/Medicaid	$754.52
Rate for Payer: Molina Healthcare Passport	$739.73
Rate for Payer: Multiplan PHCS	$846.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$987.00
Rate for Payer: UHCCP Medicaid	$493.50
Rate for Payer: Wellcare CHIP/Medicaid	$747.13

LAPAROSCOPY CHOLECYSTECTOMY

Professional

Both

$2,400.00

Service Code	HCPCS 47562
Hospital Charge Code	76101964
Hospital Revenue Code	761
Min. Negotiated Rate	$522.64
Max. Negotiated Rate	$2,400.00
Rate for Payer: Aetna Commercial	$1,060.06
Rate for Payer: Anthem Medicaid	$522.64
Rate for Payer: Buckeye Medicare Advantage	$2,400.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Cigna Commercial	$979.33
Rate for Payer: Healthspan PPO	$893.97
Rate for Payer: Humana Medicaid	$522.64
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$946.01
Rate for Payer: Molina Healthcare CHIP/Medicaid	$533.09
Rate for Payer: Molina Healthcare Passport	$522.64
Rate for Payer: Multiplan PHCS	$1,440.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,680.00
Rate for Payer: UHCCP Medicaid	$840.00
Rate for Payer: Wellcare CHIP/Medicaid	$527.87

LAPAROSCOPY CHOLECYSTECTOMY(P

Professional

Both

$2,400.00

Service Code	HCPCS 47562
Hospital Charge Code	761P1964
Hospital Revenue Code	761
Min. Negotiated Rate	$522.64
Max. Negotiated Rate	$2,400.00
Rate for Payer: Aetna Commercial	$1,060.06
Rate for Payer: Anthem Medicaid	$522.64
Rate for Payer: Buckeye Medicare Advantage	$2,400.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Cigna Commercial	$979.33
Rate for Payer: Healthspan PPO	$893.97
Rate for Payer: Humana Medicaid	$522.64
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$946.01
Rate for Payer: Molina Healthcare CHIP/Medicaid	$533.09
Rate for Payer: Molina Healthcare Passport	$522.64
Rate for Payer: Multiplan PHCS	$1,440.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,680.00
Rate for Payer: UHCCP Medicaid	$840.00
Rate for Payer: Wellcare CHIP/Medicaid	$527.87

LAPAROSCOPY DX

Professional

Both

$1,600.00

Service Code	HCPCS 49320
Hospital Charge Code	76101987
Hospital Revenue Code	761
Min. Negotiated Rate	$258.39
Max. Negotiated Rate	$1,600.00
Rate for Payer: Aetna Commercial	$476.60
Rate for Payer: Anthem Medicaid	$258.39
Rate for Payer: Buckeye Medicare Advantage	$1,600.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cigna Commercial	$450.05
Rate for Payer: Healthspan PPO	$401.92
Rate for Payer: Humana Medicaid	$258.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$417.00
Rate for Payer: Molina Healthcare CHIP/Medicaid	$263.56
Rate for Payer: Molina Healthcare Passport	$258.39
Rate for Payer: Multiplan PHCS	$960.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,120.00
Rate for Payer: UHCCP Medicaid	$560.00
Rate for Payer: Wellcare CHIP/Medicaid	$260.97

LAPAROSCOPY DX

Facility

$1,600.00

Service Code	HCPCS 49320
Hospital Charge Code	76101987
Hospital Revenue Code	761
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$1,536.00
Rate for Payer: Aetna Commercial	$1,232.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,248.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cigna Commercial	$1,328.00
Rate for Payer: First Health Commercial	$1,520.00
Rate for Payer: Humana Commercial	$1,360.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,312.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,180.80
Rate for Payer: Molina Healthcare Benefit Exchange	$480.00
Rate for Payer: Ohio Health Choice Commercial	$1,408.00
Rate for Payer: Ohio Health Group HMO	$1,200.00
Rate for Payer: Ohio Health Group PPO Differential	$320.00
Rate for Payer: Ohio Health Group PPO No Differential	$208.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$496.00
Rate for Payer: PHCS Commercial	$1,536.00
Rate for Payer: United Healthcare All Payer	$1,408.00

LAPAROSCOPY DX

Facility

$1,600.00

Service Code	HCPCS 49320
Hospital Charge Code	76101987
Hospital Revenue Code	761
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$1,232.00
Rate for Payer: Anthem Medicaid	$550.24
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$1,248.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cigna Commercial	$1,328.00
Rate for Payer: First Health Commercial	$1,520.00
Rate for Payer: Humana Commercial	$1,360.00
Rate for Payer: Humana KY Medicaid	$550.24
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$555.84
Rate for Payer: Medical Mutual Of Ohio HMO	$1,312.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,180.80
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$561.28
Rate for Payer: Ohio Health Choice Commercial	$1,408.00
Rate for Payer: Ohio Health Group HMO	$1,200.00
Rate for Payer: Ohio Health Group PPO Differential	$320.00
Rate for Payer: Ohio Health Group PPO No Differential	$208.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$496.00
Rate for Payer: PHCS Commercial	$1,536.00
Rate for Payer: United Healthcare All Payer	$1,408.00

LAPAROSCOPY DX(P

Professional

Both

$1,600.00

Service Code	HCPCS 49320
Hospital Charge Code	761P1987
Hospital Revenue Code	761
Min. Negotiated Rate	$258.39
Max. Negotiated Rate	$1,600.00
Rate for Payer: Aetna Commercial	$476.60
Rate for Payer: Anthem Medicaid	$258.39
Rate for Payer: Buckeye Medicare Advantage	$1,600.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cigna Commercial	$450.05
Rate for Payer: Healthspan PPO	$401.92
Rate for Payer: Humana Medicaid	$258.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$417.00
Rate for Payer: Molina Healthcare CHIP/Medicaid	$263.56
Rate for Payer: Molina Healthcare Passport	$258.39
Rate for Payer: Multiplan PHCS	$960.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,120.00
Rate for Payer: UHCCP Medicaid	$560.00
Rate for Payer: Wellcare CHIP/Medicaid	$260.97

LAPAROSCOPY ENTEROLYSIS

Facility

$1,250.00

Service Code	HCPCS 44180
Hospital Charge Code	76101824
Hospital Revenue Code	761
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$962.50
Rate for Payer: Anthem POS/PPO/Traditional	$975.00
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cigna Commercial	$1,037.50
Rate for Payer: First Health Commercial	$1,187.50
Rate for Payer: Humana Commercial	$1,062.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,025.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$922.50
Rate for Payer: Molina Healthcare Benefit Exchange	$375.00
Rate for Payer: Ohio Health Choice Commercial	$1,100.00
Rate for Payer: Ohio Health Group HMO	$937.50
Rate for Payer: Ohio Health Group PPO Differential	$250.00
Rate for Payer: Ohio Health Group PPO No Differential	$162.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$387.50
Rate for Payer: PHCS Commercial	$1,200.00
Rate for Payer: United Healthcare All Payer	$1,100.00

Know your out-of-pocket cost for care.

All Charges