Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

LINER LONGEVITY ELEV IT KK 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT KK 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT KK 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 36

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT LL 36

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV ITMM 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV ITMM 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT MM 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT MM 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT MM 36

Facility

$7,307.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$950.01
Max. Negotiated Rate	$7,015.44
Rate for Payer: Aetna Commercial	$5,626.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,700.04
Rate for Payer: Cash Price	$3,653.88
Rate for Payer: Cigna Commercial	$6,065.43
Rate for Payer: First Health Commercial	$6,942.36
Rate for Payer: Humana Commercial	$6,211.59
Rate for Payer: Medical Mutual Of Ohio HMO	$5,992.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,393.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,192.32
Rate for Payer: Ohio Health Choice Commercial	$6,430.82
Rate for Payer: Ohio Health Group HMO	$5,480.81
Rate for Payer: Ohio Health Group PPO Differential	$1,461.55
Rate for Payer: Ohio Health Group PPO No Differential	$950.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,265.40
Rate for Payer: PHCS Commercial	$7,015.44
Rate for Payer: United Healthcare All Payer	$6,430.82

LINER LONGEVITY ELEV IT MM 36

Facility

$7,307.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$950.01
Max. Negotiated Rate	$7,015.44
Rate for Payer: Aetna Commercial	$5,626.97
Rate for Payer: Anthem Medicaid	$2,513.14
Rate for Payer: Anthem POS/PPO/Traditional	$5,700.04
Rate for Payer: Cash Price	$3,653.88
Rate for Payer: Cigna Commercial	$6,065.43
Rate for Payer: First Health Commercial	$6,942.36
Rate for Payer: Humana Commercial	$6,211.59
Rate for Payer: Humana KY Medicaid	$2,513.14
Rate for Payer: Kentucky WC Medicaid	$2,538.71
Rate for Payer: Medical Mutual Of Ohio HMO	$5,992.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,393.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,192.32
Rate for Payer: Molina Healthcare Medicaid	$2,563.56
Rate for Payer: Ohio Health Choice Commercial	$6,430.82
Rate for Payer: Ohio Health Group HMO	$5,480.81
Rate for Payer: Ohio Health Group PPO Differential	$1,461.55
Rate for Payer: Ohio Health Group PPO No Differential	$950.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,265.40
Rate for Payer: PHCS Commercial	$7,015.44
Rate for Payer: United Healthcare All Payer	$6,430.82

LINER LONGEVITY ELEV IT NN 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT NN 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT NN 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT NN 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT NN 36

Facility

$7,307.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$950.01
Max. Negotiated Rate	$7,015.44
Rate for Payer: Aetna Commercial	$5,626.97
Rate for Payer: Anthem Medicaid	$2,513.14
Rate for Payer: Anthem POS/PPO/Traditional	$5,700.04
Rate for Payer: Cash Price	$3,653.88
Rate for Payer: Cigna Commercial	$6,065.43
Rate for Payer: First Health Commercial	$6,942.36
Rate for Payer: Humana Commercial	$6,211.59
Rate for Payer: Humana KY Medicaid	$2,513.14
Rate for Payer: Kentucky WC Medicaid	$2,538.71
Rate for Payer: Medical Mutual Of Ohio HMO	$5,992.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,393.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,192.32
Rate for Payer: Molina Healthcare Medicaid	$2,563.56
Rate for Payer: Ohio Health Choice Commercial	$6,430.82
Rate for Payer: Ohio Health Group HMO	$5,480.81
Rate for Payer: Ohio Health Group PPO Differential	$1,461.55
Rate for Payer: Ohio Health Group PPO No Differential	$950.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,265.40
Rate for Payer: PHCS Commercial	$7,015.44
Rate for Payer: United Healthcare All Payer	$6,430.82

LINER LONGEVITY ELEV IT NN 36

Facility

$7,307.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$950.01
Max. Negotiated Rate	$7,015.44
Rate for Payer: Aetna Commercial	$5,626.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,700.04
Rate for Payer: Cash Price	$3,653.88
Rate for Payer: Cigna Commercial	$6,065.43
Rate for Payer: First Health Commercial	$6,942.36
Rate for Payer: Humana Commercial	$6,211.59
Rate for Payer: Medical Mutual Of Ohio HMO	$5,992.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,393.12
Rate for Payer: Molina Healthcare Benefit Exchange	$2,192.32
Rate for Payer: Ohio Health Choice Commercial	$6,430.82
Rate for Payer: Ohio Health Group HMO	$5,480.81
Rate for Payer: Ohio Health Group PPO Differential	$1,461.55
Rate for Payer: Ohio Health Group PPO No Differential	$950.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,265.40
Rate for Payer: PHCS Commercial	$7,015.44
Rate for Payer: United Healthcare All Payer	$6,430.82

LINER LONGEVITY ELEV IT OO 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT OO 28

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT OO 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem Medicaid	$2,274.64
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Humana KY Medicaid	$2,274.64
Rate for Payer: Kentucky WC Medicaid	$2,297.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Molina Healthcare Medicaid	$2,320.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

LINER LONGEVITY ELEV IT OO 32

Facility

$6,614.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$859.85
Max. Negotiated Rate	$6,349.68
Rate for Payer: Aetna Commercial	$5,092.97
Rate for Payer: Anthem POS/PPO/Traditional	$5,159.12
Rate for Payer: Cash Price	$3,307.12
Rate for Payer: Cigna Commercial	$5,489.83
Rate for Payer: First Health Commercial	$6,283.54
Rate for Payer: Humana Commercial	$5,622.11
Rate for Payer: Medical Mutual Of Ohio HMO	$5,423.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,881.32
Rate for Payer: Molina Healthcare Benefit Exchange	$1,984.28
Rate for Payer: Ohio Health Choice Commercial	$5,820.54
Rate for Payer: Ohio Health Group HMO	$4,960.69
Rate for Payer: Ohio Health Group PPO Differential	$1,322.85
Rate for Payer: Ohio Health Group PPO No Differential	$859.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,050.42
Rate for Payer: PHCS Commercial	$6,349.68
Rate for Payer: United Healthcare All Payer	$5,820.54

Know your out-of-pocket cost for care.

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