Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

LAPAROSCOPY SALPINGOSTOMY(P

Professional

Both

$2,010.00

Service Code	HCPCS 58673
Hospital Charge Code	761P2253
Hospital Revenue Code	761
Min. Negotiated Rate	$583.55
Max. Negotiated Rate	$2,010.00
Rate for Payer: Aetna Commercial	$1,234.26
Rate for Payer: Anthem Medicaid	$583.55
Rate for Payer: Buckeye Medicare Advantage	$2,010.00
Rate for Payer: Cash Price	$1,005.00
Rate for Payer: Cash Price	$1,005.00
Rate for Payer: Cigna Commercial	$1,213.46
Rate for Payer: Healthspan PPO	$1,195.08
Rate for Payer: Humana Medicaid	$583.55
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,043.78
Rate for Payer: Molina Healthcare CHIP/Medicaid	$595.22
Rate for Payer: Molina Healthcare Passport	$583.55
Rate for Payer: Multiplan PHCS	$1,206.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,407.00
Rate for Payer: UHCCP Medicaid	$703.50
Rate for Payer: Wellcare CHIP/Medicaid	$589.39

LAPAROSCOPY SURG

Facility

$2,600.00

Service Code	HCPCS 51990
Hospital Charge Code	76102079
Hospital Revenue Code	761
Min. Negotiated Rate	$338.00
Max. Negotiated Rate	$2,496.00
Rate for Payer: Aetna Commercial	$2,002.00
Rate for Payer: Anthem POS/PPO/Traditional	$2,028.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna Commercial	$2,158.00
Rate for Payer: First Health Commercial	$2,470.00
Rate for Payer: Humana Commercial	$2,210.00
Rate for Payer: Medical Mutual Of Ohio HMO	$2,132.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,918.80
Rate for Payer: Molina Healthcare Benefit Exchange	$780.00
Rate for Payer: Ohio Health Choice Commercial	$2,288.00
Rate for Payer: Ohio Health Group HMO	$1,950.00
Rate for Payer: Ohio Health Group PPO Differential	$520.00
Rate for Payer: Ohio Health Group PPO No Differential	$338.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$806.00
Rate for Payer: PHCS Commercial	$2,496.00
Rate for Payer: United Healthcare All Payer	$2,288.00

LAPAROSCOPY SURG

Professional

Both

$2,600.00

Service Code	HCPCS 51990
Hospital Charge Code	76102079
Hospital Revenue Code	761
Min. Negotiated Rate	$534.61
Max. Negotiated Rate	$2,600.00
Rate for Payer: Aetna Commercial	$1,207.53
Rate for Payer: Anthem Medicaid	$534.61
Rate for Payer: Buckeye Medicare Advantage	$2,600.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna Commercial	$1,119.49
Rate for Payer: Healthspan PPO	$965.53
Rate for Payer: Humana Medicaid	$534.61
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,025.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$545.30
Rate for Payer: Molina Healthcare Passport	$534.61
Rate for Payer: Multiplan PHCS	$1,560.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,820.00
Rate for Payer: UHCCP Medicaid	$910.00
Rate for Payer: Wellcare CHIP/Medicaid	$539.96

LAPAROSCOPY SURG

Facility

$2,600.00

Service Code	HCPCS 51990
Hospital Charge Code	76102079
Hospital Revenue Code	761
Min. Negotiated Rate	$338.00
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$2,002.00
Rate for Payer: Anthem Medicaid	$894.14
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$2,028.00
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	$1,300.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna Commercial	$2,158.00
Rate for Payer: First Health Commercial	$2,470.00
Rate for Payer: Humana Commercial	$2,210.00
Rate for Payer: Humana KY Medicaid	$894.14
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$903.24
Rate for Payer: Medical Mutual Of Ohio HMO	$2,132.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,918.80
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$912.08
Rate for Payer: Ohio Health Choice Commercial	$2,288.00
Rate for Payer: Ohio Health Group HMO	$1,950.00
Rate for Payer: Ohio Health Group PPO Differential	$520.00
Rate for Payer: Ohio Health Group PPO No Differential	$338.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$806.00
Rate for Payer: PHCS Commercial	$2,496.00
Rate for Payer: United Healthcare All Payer	$2,288.00

LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S), INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, WHEN PERFORMED

Facility

$12,462.13

Service Code	CPT 50542
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL, APPENDECTOMY

Facility

$6,985.45

Service Code	CPT 44970
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, SURGICAL; CHOLECYSTECTOMY

Facility

$6,985.45

Service Code	CPT 47562
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, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY

Facility

$6,985.45

Service Code	CPT 47563
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, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT

Facility

$12,462.13

Service Code	CPT 47564
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)

Facility

$6,985.45

Service Code	CPT 44180
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 - SURGICAL - ESO

Facility

$1,650.00

Service Code	HCPCS 43280
Hospital Charge Code	76101764
Hospital Revenue Code	761
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$1,584.00
Rate for Payer: Aetna Commercial	$1,270.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,287.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cigna Commercial	$1,369.50
Rate for Payer: First Health Commercial	$1,567.50
Rate for Payer: Humana Commercial	$1,402.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,353.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,217.70
Rate for Payer: Molina Healthcare Benefit Exchange	$495.00
Rate for Payer: Ohio Health Choice Commercial	$1,452.00
Rate for Payer: Ohio Health Group HMO	$1,237.50
Rate for Payer: Ohio Health Group PPO Differential	$330.00
Rate for Payer: Ohio Health Group PPO No Differential	$214.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$511.50
Rate for Payer: PHCS Commercial	$1,584.00
Rate for Payer: United Healthcare All Payer	$1,452.00

LAPAROSCOPY - SURGICAL - ESO

Facility

$1,650.00

Service Code	HCPCS 43280
Hospital Charge Code	76101764
Hospital Revenue Code	761
Min. Negotiated Rate	$214.50
Max. Negotiated Rate	$12,462.13
Rate for Payer: Aetna Commercial	$1,270.50
Rate for Payer: Anthem Medicaid	$567.44
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Anthem POS/PPO/Traditional	$1,287.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cigna Commercial	$1,369.50
Rate for Payer: First Health Commercial	$1,567.50
Rate for Payer: Humana Commercial	$1,402.50
Rate for Payer: Humana KY Medicaid	$567.44
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Kentucky WC Medicaid	$573.21
Rate for Payer: Medical Mutual Of Ohio HMO	$1,353.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,217.70
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82
Rate for Payer: Molina Healthcare Medicaid	$578.82
Rate for Payer: Ohio Health Choice Commercial	$1,452.00
Rate for Payer: Ohio Health Group HMO	$1,237.50
Rate for Payer: Ohio Health Group PPO Differential	$330.00
Rate for Payer: Ohio Health Group PPO No Differential	$214.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$511.50
Rate for Payer: PHCS Commercial	$1,584.00
Rate for Payer: United Healthcare All Payer	$1,452.00

LAPAROSCOPY - SURGICAL - ESO

Professional

Both

$1,650.00

Service Code	HCPCS 43280
Hospital Charge Code	76101764
Hospital Revenue Code	761
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$1,650.00
Rate for Payer: Aetna Commercial	$1,578.22
Rate for Payer: Anthem Medicaid	$820.29
Rate for Payer: Buckeye Medicare Advantage	$1,650.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cigna Commercial	$1,478.24
Rate for Payer: Healthspan PPO	$1,330.94
Rate for Payer: Humana Medicaid	$820.29
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,386.93
Rate for Payer: Molina Healthcare CHIP/Medicaid	$836.70
Rate for Payer: Molina Healthcare Passport	$820.29
Rate for Payer: Multiplan PHCS	$990.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,155.00
Rate for Payer: UHCCP Medicaid	$577.50
Rate for Payer: Wellcare CHIP/Medicaid	$828.49

LAPAROSCOPY - SURGICAL - ESO(P

Professional

Both

$1,650.00

Service Code	HCPCS 43280
Hospital Charge Code	761P1764
Hospital Revenue Code	761
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$1,650.00
Rate for Payer: Aetna Commercial	$1,578.22
Rate for Payer: Anthem Medicaid	$820.29
Rate for Payer: Buckeye Medicare Advantage	$1,650.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cash Price	$825.00
Rate for Payer: Cigna Commercial	$1,478.24
Rate for Payer: Healthspan PPO	$1,330.94
Rate for Payer: Humana Medicaid	$820.29
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,386.93
Rate for Payer: Molina Healthcare CHIP/Medicaid	$836.70
Rate for Payer: Molina Healthcare Passport	$820.29
Rate for Payer: Multiplan PHCS	$990.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,155.00
Rate for Payer: UHCCP Medicaid	$577.50
Rate for Payer: Wellcare CHIP/Medicaid	$828.49

LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)

Facility

$12,462.13

Service Code	CPT 43280
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA

Facility

$6,985.45

Service Code	CPT 49650
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, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH

Facility

$12,462.13

Service Code	CPT 43282
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH

Facility

$12,462.13

Service Code	CPT 43281
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA

Facility

$6,985.45

Service Code	CPT 49651
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, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)

Facility

$12,462.13

Service Code	CPT 58542
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)

Facility

$6,985.45

Service Code	CPT 49322
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, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)

Facility

$6,985.45

Service Code	CPT 49321
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, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD

Facility

$6,985.45

Service Code	CPT 58662
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, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER

Facility

$6,985.45

Service Code	CPT 49324
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, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)

Facility

$6,985.45

Service Code	CPT 58660
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

Know your out-of-pocket cost for care.

All Charges