Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE RING)

Facility

$6,985.45

Service Code	CPT 58671
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 REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)

Facility

$6,985.45

Service Code	CPT 58661
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 TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;

Facility

$12,462.13

Service Code	CPT 58570
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 TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)

Facility

$12,462.13

Service Code	CPT 58571
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 TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)

Facility

$12,462.13

Service Code	CPT 58573
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 SURG(P

Professional

Both

$2,600.00

Service Code	HCPCS 51990
Hospital Charge Code	761P2079
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, SPLENECTOMY

Facility

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	76102571
Hospital Revenue Code	761
Min. Negotiated Rate	$165.10
Max. Negotiated Rate	$12,462.13
Rate for Payer: Aetna Commercial	$977.90
Rate for Payer: Anthem Medicaid	$436.75
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Anthem POS/PPO/Traditional	$990.60
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	$635.00
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cigna Commercial	$1,054.10
Rate for Payer: First Health Commercial	$1,206.50
Rate for Payer: Humana Commercial	$1,079.50
Rate for Payer: Humana KY Medicaid	$436.75
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Kentucky WC Medicaid	$441.20
Rate for Payer: Medical Mutual Of Ohio HMO	$1,041.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$937.26
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82
Rate for Payer: Molina Healthcare Medicaid	$445.52
Rate for Payer: Ohio Health Choice Commercial	$1,117.60
Rate for Payer: Ohio Health Group HMO	$952.50
Rate for Payer: Ohio Health Group PPO Differential	$254.00
Rate for Payer: Ohio Health Group PPO No Differential	$165.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$393.70
Rate for Payer: PHCS Commercial	$1,219.20
Rate for Payer: United Healthcare All Payer	$1,117.60

LAPAROSCOPY, SURG, SPLENECTOMY

Professional

Both

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	761P2571
Hospital Revenue Code	761
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$1,525.71
Rate for Payer: Aetna Commercial	$1,525.71
Rate for Payer: Anthem Medicaid	$683.05
Rate for Payer: Buckeye Medicare Advantage	$1,270.00
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cigna Commercial	$1,429.36
Rate for Payer: Healthspan PPO	$1,219.94
Rate for Payer: Humana Medicaid	$683.05
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,340.31
Rate for Payer: Molina Healthcare CHIP/Medicaid	$696.71
Rate for Payer: Molina Healthcare Passport	$683.05
Rate for Payer: Multiplan PHCS	$762.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$889.00
Rate for Payer: UHCCP Medicaid	$444.50
Rate for Payer: Wellcare CHIP/Medicaid	$689.88

LAPAROSCOPY, SURG, SPLENECTOMY

Professional

Both

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	76102571
Hospital Revenue Code	761
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$1,525.71
Rate for Payer: Aetna Commercial	$1,525.71
Rate for Payer: Anthem Medicaid	$683.05
Rate for Payer: Buckeye Medicare Advantage	$1,270.00
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cigna Commercial	$1,429.36
Rate for Payer: Healthspan PPO	$1,219.94
Rate for Payer: Humana Medicaid	$683.05
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,340.31
Rate for Payer: Molina Healthcare CHIP/Medicaid	$696.71
Rate for Payer: Molina Healthcare Passport	$683.05
Rate for Payer: Multiplan PHCS	$762.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$889.00
Rate for Payer: UHCCP Medicaid	$444.50
Rate for Payer: Wellcare CHIP/Medicaid	$689.88

LAPAROSCOPY, SURG, SPLENECTOMY

Facility

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	76102571
Hospital Revenue Code	761
Min. Negotiated Rate	$165.10
Max. Negotiated Rate	$1,219.20
Rate for Payer: Aetna Commercial	$977.90
Rate for Payer: Anthem POS/PPO/Traditional	$990.60
Rate for Payer: Cash Price	$635.00
Rate for Payer: Cigna Commercial	$1,054.10
Rate for Payer: First Health Commercial	$1,206.50
Rate for Payer: Humana Commercial	$1,079.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,041.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$937.26
Rate for Payer: Molina Healthcare Benefit Exchange	$381.00
Rate for Payer: Ohio Health Choice Commercial	$1,117.60
Rate for Payer: Ohio Health Group HMO	$952.50
Rate for Payer: Ohio Health Group PPO Differential	$254.00
Rate for Payer: Ohio Health Group PPO No Differential	$165.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$393.70
Rate for Payer: PHCS Commercial	$1,219.20
Rate for Payer: United Healthcare All Payer	$1,117.60

LAPAROSCOPY VAGUS NERVE

Facility

$7,883.00

Service Code	HCPCS 43651
Hospital Charge Code	76101787
Hospital Revenue Code	761
Min. Negotiated Rate	$1,024.79
Max. Negotiated Rate	$7,567.68
Rate for Payer: Aetna Commercial	$6,069.91
Rate for Payer: Anthem Medicaid	$2,710.96
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$6,148.74
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	$3,941.50
Rate for Payer: Cash Price	$3,941.50
Rate for Payer: Cigna Commercial	$6,542.89
Rate for Payer: First Health Commercial	$7,488.85
Rate for Payer: Humana Commercial	$6,700.55
Rate for Payer: Humana KY Medicaid	$2,710.96
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$2,738.55
Rate for Payer: Medical Mutual Of Ohio HMO	$6,464.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,817.65
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$2,765.36
Rate for Payer: Ohio Health Choice Commercial	$6,937.04
Rate for Payer: Ohio Health Group HMO	$5,912.25
Rate for Payer: Ohio Health Group PPO Differential	$1,576.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,024.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,443.73
Rate for Payer: PHCS Commercial	$7,567.68
Rate for Payer: United Healthcare All Payer	$6,937.04

LAPAROSCOPY VAGUS NERVE

Professional

Both

$7,883.00

Service Code	HCPCS 43651
Hospital Charge Code	76101787
Hospital Revenue Code	761
Min. Negotiated Rate	$448.81
Max. Negotiated Rate	$7,883.00
Rate for Payer: Aetna Commercial	$937.44
Rate for Payer: Anthem Medicaid	$448.81
Rate for Payer: Buckeye Medicare Advantage	$7,883.00
Rate for Payer: Cash Price	$3,941.50
Rate for Payer: Cash Price	$3,941.50
Rate for Payer: Cigna Commercial	$874.04
Rate for Payer: Healthspan PPO	$790.56
Rate for Payer: Humana Medicaid	$448.81
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$826.59
Rate for Payer: Molina Healthcare CHIP/Medicaid	$457.79
Rate for Payer: Molina Healthcare Passport	$448.81
Rate for Payer: Multiplan PHCS	$4,729.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5,518.10
Rate for Payer: UHCCP Medicaid	$2,759.05
Rate for Payer: Wellcare CHIP/Medicaid	$453.30

LAPAROSCOPY VAGUS NERVE

Facility

$7,883.00

Service Code	HCPCS 43651
Hospital Charge Code	76101787
Hospital Revenue Code	761
Min. Negotiated Rate	$1,024.79
Max. Negotiated Rate	$7,567.68
Rate for Payer: Aetna Commercial	$6,069.91
Rate for Payer: Anthem POS/PPO/Traditional	$6,148.74
Rate for Payer: Cash Price	$3,941.50
Rate for Payer: Cigna Commercial	$6,542.89
Rate for Payer: First Health Commercial	$7,488.85
Rate for Payer: Humana Commercial	$6,700.55
Rate for Payer: Medical Mutual Of Ohio HMO	$6,464.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,817.65
Rate for Payer: Molina Healthcare Benefit Exchange	$2,364.90
Rate for Payer: Ohio Health Choice Commercial	$6,937.04
Rate for Payer: Ohio Health Group HMO	$5,912.25
Rate for Payer: Ohio Health Group PPO Differential	$1,576.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,024.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,443.73
Rate for Payer: PHCS Commercial	$7,567.68
Rate for Payer: United Healthcare All Payer	$6,937.04

LAPAROSCOPY VAGUS NERVE(P

Professional

Both

$960.00

Service Code	HCPCS 43651
Hospital Charge Code	761P1787
Hospital Revenue Code	761
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$960.00
Rate for Payer: Aetna Commercial	$937.44
Rate for Payer: Anthem Medicaid	$448.81
Rate for Payer: Buckeye Medicare Advantage	$960.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cigna Commercial	$874.04
Rate for Payer: Healthspan PPO	$790.56
Rate for Payer: Humana Medicaid	$448.81
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$826.59
Rate for Payer: Molina Healthcare CHIP/Medicaid	$457.79
Rate for Payer: Molina Healthcare Passport	$448.81
Rate for Payer: Multiplan PHCS	$576.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$672.00
Rate for Payer: UHCCP Medicaid	$336.00
Rate for Payer: Wellcare CHIP/Medicaid	$453.30

LAPAROSCOPY VAGUS NERVE(T

Facility

$6,923.00

Service Code	HCPCS 43651
Hospital Charge Code	761T1787
Hospital Revenue Code	761
Min. Negotiated Rate	$899.99
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$5,330.71
Rate for Payer: Anthem Medicaid	$2,380.82
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$5,399.94
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	$3,461.50
Rate for Payer: Cash Price	$3,461.50
Rate for Payer: Cigna Commercial	$5,746.09
Rate for Payer: First Health Commercial	$6,576.85
Rate for Payer: Humana Commercial	$5,884.55
Rate for Payer: Humana KY Medicaid	$2,380.82
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$2,405.05
Rate for Payer: Medical Mutual Of Ohio HMO	$5,676.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,109.17
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$2,428.59
Rate for Payer: Ohio Health Choice Commercial	$6,092.24
Rate for Payer: Ohio Health Group HMO	$5,192.25
Rate for Payer: Ohio Health Group PPO Differential	$1,384.60
Rate for Payer: Ohio Health Group PPO No Differential	$899.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,146.13
Rate for Payer: PHCS Commercial	$6,646.08
Rate for Payer: United Healthcare All Payer	$6,092.24

LAPAROSCOPY VAGUS NERVE(T

Facility

$6,923.00

Service Code	HCPCS 43651
Hospital Charge Code	761T1787
Hospital Revenue Code	761
Min. Negotiated Rate	$899.99
Max. Negotiated Rate	$6,646.08
Rate for Payer: Aetna Commercial	$5,330.71
Rate for Payer: Anthem POS/PPO/Traditional	$5,399.94
Rate for Payer: Cash Price	$3,461.50
Rate for Payer: Cigna Commercial	$5,746.09
Rate for Payer: First Health Commercial	$6,576.85
Rate for Payer: Humana Commercial	$5,884.55
Rate for Payer: Medical Mutual Of Ohio HMO	$5,676.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,109.17
Rate for Payer: Molina Healthcare Benefit Exchange	$2,076.90
Rate for Payer: Ohio Health Choice Commercial	$6,092.24
Rate for Payer: Ohio Health Group HMO	$5,192.25
Rate for Payer: Ohio Health Group PPO Differential	$1,384.60
Rate for Payer: Ohio Health Group PPO No Differential	$899.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,146.13
Rate for Payer: PHCS Commercial	$6,646.08
Rate for Payer: United Healthcare All Payer	$6,092.24

LAPAROSCOPY W/TKDWN FUNDOPLICA

Professional

Both

$2,305.00

Service Code	HCPCS 43289
Hospital Charge Code	76102758
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2,305.00
Rate for Payer: Buckeye Medicare Advantage	$2,305.00
Rate for Payer: Cash Price	$1,152.50
Rate for Payer: Cash Price	$1,152.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,383.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,613.50
Rate for Payer: UHCCP Medicaid	$806.75

LAPAROSC UNROOFING SPLEN CYST

Professional

Both

$935.00

Service Code	HCPCS 38129
Hospital Charge Code	76102930
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$935.00
Rate for Payer: Buckeye Medicare Advantage	$935.00
Rate for Payer: Cash Price	$467.50
Rate for Payer: Cash Price	$467.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$561.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$654.50
Rate for Payer: UHCCP Medicaid	$327.25

LAPAROSC UNROOFING SPLEN CYST

Facility

$935.00

Service Code	HCPCS 38129
Hospital Charge Code	76102930
Hospital Revenue Code	761
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$6,985.45
Rate for Payer: Aetna Commercial	$719.95
Rate for Payer: Anthem Medicaid	$321.55
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$729.30
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	$467.50
Rate for Payer: Cash Price	$467.50
Rate for Payer: Cigna Commercial	$776.05
Rate for Payer: First Health Commercial	$888.25
Rate for Payer: Humana Commercial	$794.75
Rate for Payer: Humana KY Medicaid	$321.55
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$324.82
Rate for Payer: Medical Mutual Of Ohio HMO	$766.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$690.03
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$328.00
Rate for Payer: Ohio Health Choice Commercial	$822.80
Rate for Payer: Ohio Health Group HMO	$701.25
Rate for Payer: Ohio Health Group PPO Differential	$187.00
Rate for Payer: Ohio Health Group PPO No Differential	$121.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$289.85
Rate for Payer: PHCS Commercial	$897.60
Rate for Payer: United Healthcare All Payer	$822.80

LAPAROSC UNROOFING SPLEN CYST

Facility

$935.00

Service Code	HCPCS 38129
Hospital Charge Code	76102930
Hospital Revenue Code	761
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$897.60
Rate for Payer: Aetna Commercial	$719.95
Rate for Payer: Anthem POS/PPO/Traditional	$729.30
Rate for Payer: Cash Price	$467.50
Rate for Payer: Cigna Commercial	$776.05
Rate for Payer: First Health Commercial	$888.25
Rate for Payer: Humana Commercial	$794.75
Rate for Payer: Medical Mutual Of Ohio HMO	$766.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$690.03
Rate for Payer: Molina Healthcare Benefit Exchange	$280.50
Rate for Payer: Ohio Health Choice Commercial	$822.80
Rate for Payer: Ohio Health Group HMO	$701.25
Rate for Payer: Ohio Health Group PPO Differential	$187.00
Rate for Payer: Ohio Health Group PPO No Differential	$121.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$289.85
Rate for Payer: PHCS Commercial	$897.60
Rate for Payer: United Healthcare All Payer	$822.80

LAPARO-VAG HYST W/T/O COMPL

Professional

Both

$1,800.00

Service Code	HCPCS 58554
Hospital Charge Code	76102232
Hospital Revenue Code	761
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$1,976.53
Rate for Payer: Aetna Commercial	$1,976.53
Rate for Payer: Anthem Medicaid	$816.75
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: Cigna Commercial	$1,943.80
Rate for Payer: Healthspan PPO	$1,913.78
Rate for Payer: Humana Medicaid	$816.75
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,712.23
Rate for Payer: Molina Healthcare CHIP/Medicaid	$833.08
Rate for Payer: Molina Healthcare Passport	$816.75
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
Rate for Payer: Wellcare CHIP/Medicaid	$824.92

LAPARO-VAG HYST W/T/O COMPL

Facility

$1,800.00

Service Code	HCPCS 58554
Hospital Charge Code	76102232
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$12,462.13
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem Medicaid	$619.02
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
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	$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	$8,901.52
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	$10,681.82
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

LAPARO-VAG HYST W/T/O COMPL

Facility

$1,800.00

Service Code	HCPCS 58554
Hospital Charge Code	76102232
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

LAPARO-VAG HYST W/T/O COMPL(P

Professional

Both

$1,800.00

Service Code	HCPCS 58554
Hospital Charge Code	761P2232
Hospital Revenue Code	761
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$1,976.53
Rate for Payer: Aetna Commercial	$1,976.53
Rate for Payer: Anthem Medicaid	$816.75
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: Cigna Commercial	$1,943.80
Rate for Payer: Healthspan PPO	$1,913.78
Rate for Payer: Humana Medicaid	$816.75
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,712.23
Rate for Payer: Molina Healthcare CHIP/Medicaid	$833.08
Rate for Payer: Molina Healthcare Passport	$816.75
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
Rate for Payer: Wellcare CHIP/Medicaid	$824.92

LAPBAND ADJUSTMENT

Professional

Both

$150.00

Service Code	HCPCS 98926
Hospital Charge Code	51000148
Hospital Revenue Code	510
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$32.74
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$17.82
Rate for Payer: Anthem Medicaid	$30.53
Rate for Payer: Buckeye Medicare Advantage	$150.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cigna Commercial	$52.96
Rate for Payer: Humana Medicaid	$30.53
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$41.52
Rate for Payer: Molina Healthcare CHIP/Medicaid	$31.14
Rate for Payer: Molina Healthcare Passport	$30.53
Rate for Payer: Multiplan PHCS	$90.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$105.00
Rate for Payer: UHCCP Medicaid	$18.71
Rate for Payer: Wellcare CHIP/Medicaid	$30.84

Know your out-of-pocket cost for care.

All Charges