Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH

Facility

$13,467.66

Service Code	CPT 43282
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

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

Facility

$13,467.66

Service Code	CPT 43281
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA

Facility

$7,547.16

Service Code	CPT 49651
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

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

Facility

$13,467.66

Service Code	CPT 58542
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

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

Facility

$7,547.16

Service Code	CPT 49322
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)

Facility

$7,547.16

Service Code	CPT 49321
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD

Facility

$7,547.16

Service Code	CPT 58662
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER

Facility

$7,547.16

Service Code	CPT 49324
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE)

Facility

$7,547.16

Service Code	CPT 58660
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

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

Facility

$7,547.16

Service Code	CPT 58671
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)

Facility

$7,547.16

Service Code	CPT 58661
Hospital Revenue Code	360
Min. Negotiated Rate	$5,390.83
Max. Negotiated Rate	$7,547.16
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
Rate for Payer: Humana Medicare Advantage	$5,390.83
Rate for Payer: Molina Healthcare Benefit Exchange	$6,469.00

LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;

Facility

$13,467.66

Service Code	CPT 58570
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)

Facility

$13,467.66

Service Code	CPT 58571
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)

Facility

$13,467.66

Service Code	CPT 58573
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

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	$1,560.00
Rate for Payer: Aetna Commercial	$1,207.53
Rate for Payer: Ambetter Exchange	$704.24
Rate for Payer: Anthem Medicaid	$534.61
Rate for Payer: Buckeye Individual/Medicaid	$704.24
Rate for Payer: Buckeye Medicare Advantage	$704.24
Rate for Payer: CareSource Just4Me Medicare	$845.09
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: Medical Mutual Of Ohio Medicare Advantage	$704.24
Rate for Payer: Molina Healthcare Benefit Exchange	$704.24
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	$915.51
Rate for Payer: UHCCP Medicaid	$910.00
Rate for Payer: Wellcare CHIP/Medicaid	$539.96
Rate for Payer: Wellcare Medicare Advantage	$704.24

LAPAROSCOPY, SURG, SPLENECTOMY

Facility

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	76102571
Hospital Revenue Code	761
Min. Negotiated Rate	$436.75
Max. Negotiated Rate	$13,467.66
Rate for Payer: Aetna Commercial	$977.90
Rate for Payer: Anthem Medicaid	$436.75
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Anthem POS/PPO/Traditional	$990.60
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
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	$9,619.76
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	$11,543.71
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	$1,016.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,104.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$876.30
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: Ambetter Exchange	$1,009.72
Rate for Payer: Anthem Medicaid	$683.05
Rate for Payer: Buckeye Individual/Medicaid	$1,009.72
Rate for Payer: Buckeye Medicare Advantage	$1,009.72
Rate for Payer: CareSource Just4Me Medicare	$1,211.66
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: Medical Mutual Of Ohio Medicare Advantage	$1,009.72
Rate for Payer: Molina Healthcare Benefit Exchange	$1,009.72
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	$1,312.64
Rate for Payer: UHCCP Medicaid	$444.50
Rate for Payer: Wellcare CHIP/Medicaid	$689.88
Rate for Payer: Wellcare Medicare Advantage	$1,009.72

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: Ambetter Exchange	$1,009.72
Rate for Payer: Anthem Medicaid	$683.05
Rate for Payer: Buckeye Individual/Medicaid	$1,009.72
Rate for Payer: Buckeye Medicare Advantage	$1,009.72
Rate for Payer: CareSource Just4Me Medicare	$1,211.66
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: Medical Mutual Of Ohio Medicare Advantage	$1,009.72
Rate for Payer: Molina Healthcare Benefit Exchange	$1,009.72
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	$1,312.64
Rate for Payer: UHCCP Medicaid	$444.50
Rate for Payer: Wellcare CHIP/Medicaid	$689.88
Rate for Payer: Wellcare Medicare Advantage	$1,009.72

LAPAROSCOPY, SURG, SPLENECTOMY

Facility

$1,270.00

Service Code	HCPCS 38120
Hospital Charge Code	76102571
Hospital Revenue Code	761
Min. Negotiated Rate	$381.00
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	$1,016.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,104.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$876.30
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	$2,364.90
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	$6,306.40
Rate for Payer: Ohio Health Group PPO No Differential	$6,858.21
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,439.27
Rate for Payer: PHCS Commercial	$7,567.68
Rate for Payer: United Healthcare All Payer	$6,937.04

LAPAROSCOPY VAGUS NERVE

Facility

$7,883.00

Service Code	HCPCS 43651
Hospital Charge Code	76101787
Hospital Revenue Code	761
Min. Negotiated Rate	$2,710.96
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	$5,390.83
Rate for Payer: Anthem POS/PPO/Traditional	$6,148.74
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
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	$5,390.83
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	$6,469.00
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	$6,306.40
Rate for Payer: Ohio Health Group PPO No Differential	$6,858.21
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,439.27
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	$4,729.80
Rate for Payer: Aetna Commercial	$937.44
Rate for Payer: Ambetter Exchange	$628.74
Rate for Payer: Anthem Medicaid	$448.81
Rate for Payer: Buckeye Individual/Medicaid	$628.74
Rate for Payer: Buckeye Medicare Advantage	$628.74
Rate for Payer: CareSource Just4Me Medicare	$754.49
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: Medical Mutual Of Ohio Medicare Advantage	$628.74
Rate for Payer: Molina Healthcare Benefit Exchange	$628.74
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	$817.36
Rate for Payer: UHCCP Medicaid	$2,759.05
Rate for Payer: Wellcare CHIP/Medicaid	$453.30
Rate for Payer: Wellcare Medicare Advantage	$628.74

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	$937.44
Rate for Payer: Aetna Commercial	$937.44
Rate for Payer: Ambetter Exchange	$628.74
Rate for Payer: Anthem Medicaid	$448.81
Rate for Payer: Buckeye Individual/Medicaid	$628.74
Rate for Payer: Buckeye Medicare Advantage	$628.74
Rate for Payer: CareSource Just4Me Medicare	$754.49
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: Medical Mutual Of Ohio Medicare Advantage	$628.74
Rate for Payer: Molina Healthcare Benefit Exchange	$628.74
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	$817.36
Rate for Payer: UHCCP Medicaid	$336.00
Rate for Payer: Wellcare CHIP/Medicaid	$453.30
Rate for Payer: Wellcare Medicare Advantage	$628.74

LAPAROSCOPY VAGUS NERVE(T

Facility

$6,923.00

Service Code	HCPCS 43651
Hospital Charge Code	761T1787
Hospital Revenue Code	761
Min. Negotiated Rate	$2,380.82
Max. Negotiated Rate	$7,547.16
Rate for Payer: Aetna Commercial	$5,330.71
Rate for Payer: Anthem Medicaid	$2,380.82
Rate for Payer: Anthem Medicare Advantage/PPO	$5,390.83
Rate for Payer: Anthem POS/PPO/Traditional	$5,399.94
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,547.16
Rate for Payer: CareSource Just4Me Medicare	$7,277.62
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	$5,390.83
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	$6,469.00
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	$5,538.40
Rate for Payer: Ohio Health Group PPO No Differential	$6,023.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,776.87
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	$2,076.90
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	$5,538.40
Rate for Payer: Ohio Health Group PPO No Differential	$6,023.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,776.87
Rate for Payer: PHCS Commercial	$6,646.08
Rate for Payer: United Healthcare All Payer	$6,092.24

Know your out-of-pocket cost for care.

All Charges