Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION

Facility

$16,644.15

Service Code	CPT 24545
Hospital Revenue Code	360
Min. Negotiated Rate	$11,888.68
Max. Negotiated Rate	$16,644.15
Rate for Payer: Anthem Medicare Advantage/PPO	$11,888.68
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$16,644.15
Rate for Payer: CareSource Just4Me Medicare	$16,049.72
Rate for Payer: Humana Medicare Advantage	$11,888.68
Rate for Payer: Molina Healthcare Benefit Exchange	$14,266.42

OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,240.92

Service Code	CPT 27766
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE

Facility

$4,197.13

Service Code	CPT 26615
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$4,197.13

Service Code	CPT 26715
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH

Facility

$9,240.92

Service Code	CPT 28485
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR

Facility

$9,240.92

Service Code	CPT 27524
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH

Facility

$4,197.13

Service Code	CPT 26735
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;

Facility

$16,644.15

Service Code	CPT 23615
Hospital Revenue Code	360
Min. Negotiated Rate	$11,888.68
Max. Negotiated Rate	$16,644.15
Rate for Payer: Anthem Medicare Advantage/PPO	$11,888.68
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$16,644.15
Rate for Payer: CareSource Just4Me Medicare	$16,049.72
Rate for Payer: Humana Medicare Advantage	$11,888.68
Rate for Payer: Molina Healthcare Benefit Exchange	$14,266.42

OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA

Facility

$9,240.92

Service Code	CPT 25575
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;

Facility

$9,240.92

Service Code	CPT 24665
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,240.92

Service Code	CPT 25515
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, AND OPEN TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TRIANGULAR FIBROCARTILAGE COMPLEX

Facility

$9,240.92

Service Code	CPT 25526
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH

Facility

$9,240.92

Service Code	CPT 28465
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,240.92

Service Code	CPT 28615
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE

Facility

$16,644.15

Service Code	CPT 27758
Hospital Revenue Code	360
Min. Negotiated Rate	$11,888.68
Max. Negotiated Rate	$16,644.15
Rate for Payer: Anthem Medicare Advantage/PPO	$11,888.68
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$16,644.15
Rate for Payer: CareSource Just4Me Medicare	$16,049.72
Rate for Payer: Humana Medicare Advantage	$11,888.68
Rate for Payer: Molina Healthcare Benefit Exchange	$14,266.42

OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP

Facility

$9,240.92

Service Code	CPT 27822
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,240.92

Service Code	CPT 24685
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$9,240.92

Service Code	CPT 25545
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

OPEN TREATMENT ULNAR FX PROX

Facility

$1,375.00

Service Code	HCPCS 24685
Hospital Charge Code	76100563
Hospital Revenue Code	761
Min. Negotiated Rate	$472.86
Max. Negotiated Rate	$9,240.92
Rate for Payer: Aetna Commercial	$1,058.75
Rate for Payer: Anthem Medicaid	$472.86
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Anthem POS/PPO/Traditional	$1,072.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cigna Commercial	$1,141.25
Rate for Payer: First Health Commercial	$1,306.25
Rate for Payer: Humana Commercial	$1,168.75
Rate for Payer: Humana KY Medicaid	$472.86
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Kentucky WC Medicaid	$477.68
Rate for Payer: Medical Mutual Of Ohio HMO	$1,127.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,014.75
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79
Rate for Payer: Molina Healthcare Medicaid	$482.35
Rate for Payer: Ohio Health Choice Commercial	$1,210.00
Rate for Payer: Ohio Health Group HMO	$1,031.25
Rate for Payer: Ohio Health Group PPO Differential	$1,100.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,196.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$948.75
Rate for Payer: PHCS Commercial	$1,320.00
Rate for Payer: United Healthcare All Payer	$1,210.00

OPEN TREATMENT ULNAR FX PROX

Facility

$1,375.00

Service Code	HCPCS 24685
Hospital Charge Code	76100563
Hospital Revenue Code	761
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$1,320.00
Rate for Payer: Aetna Commercial	$1,058.75
Rate for Payer: Anthem POS/PPO/Traditional	$1,072.50
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cigna Commercial	$1,141.25
Rate for Payer: First Health Commercial	$1,306.25
Rate for Payer: Humana Commercial	$1,168.75
Rate for Payer: Medical Mutual Of Ohio HMO	$1,127.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,014.75
Rate for Payer: Molina Healthcare Benefit Exchange	$412.50
Rate for Payer: Ohio Health Choice Commercial	$1,210.00
Rate for Payer: Ohio Health Group HMO	$1,031.25
Rate for Payer: Ohio Health Group PPO Differential	$1,100.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,196.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$948.75
Rate for Payer: PHCS Commercial	$1,320.00
Rate for Payer: United Healthcare All Payer	$1,210.00

OPEN TREATMENT ULNAR FX PROX

Professional

Both

$1,375.00

Service Code	HCPCS 24685
Hospital Charge Code	76100563
Hospital Revenue Code	761
Min. Negotiated Rate	$481.25
Max. Negotiated Rate	$1,085.82
Rate for Payer: Aetna Commercial	$950.90
Rate for Payer: Ambetter Exchange	$624.09
Rate for Payer: Anthem Medicaid	$502.59
Rate for Payer: Buckeye Individual/Medicaid	$624.09
Rate for Payer: Buckeye Medicare Advantage	$624.09
Rate for Payer: CareSource Just4Me Medicare	$748.91
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cigna Commercial	$1,085.82
Rate for Payer: Healthspan PPO	$861.31
Rate for Payer: Humana Medicaid	$502.59
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$802.00
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$624.09
Rate for Payer: Molina Healthcare Benefit Exchange	$624.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$512.64
Rate for Payer: Molina Healthcare Passport	$502.59
Rate for Payer: Multiplan PHCS	$825.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$811.32
Rate for Payer: UHCCP Medicaid	$481.25
Rate for Payer: Wellcare CHIP/Medicaid	$507.62
Rate for Payer: Wellcare Medicare Advantage	$624.09

OPEN TREATMENT ULNAR FX PROX(P

Professional

Both

$1,375.00

Service Code	HCPCS 24685
Hospital Charge Code	761P0563
Hospital Revenue Code	761
Min. Negotiated Rate	$481.25
Max. Negotiated Rate	$1,085.82
Rate for Payer: Aetna Commercial	$950.90
Rate for Payer: Ambetter Exchange	$624.09
Rate for Payer: Anthem Medicaid	$502.59
Rate for Payer: Buckeye Individual/Medicaid	$624.09
Rate for Payer: Buckeye Medicare Advantage	$624.09
Rate for Payer: CareSource Just4Me Medicare	$748.91
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cash Price	$687.50
Rate for Payer: Cigna Commercial	$1,085.82
Rate for Payer: Healthspan PPO	$861.31
Rate for Payer: Humana Medicaid	$502.59
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$802.00
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$624.09
Rate for Payer: Molina Healthcare Benefit Exchange	$624.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$512.64
Rate for Payer: Molina Healthcare Passport	$502.59
Rate for Payer: Multiplan PHCS	$825.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$811.32
Rate for Payer: UHCCP Medicaid	$481.25
Rate for Payer: Wellcare CHIP/Medicaid	$507.62
Rate for Payer: Wellcare Medicare Advantage	$624.09

OPEN TREAT. OF METACAR. DISLOC

Facility

$1,100.00

Service Code	HCPCS 26686
Hospital Charge Code	76100732
Hospital Revenue Code	761
Min. Negotiated Rate	$330.00
Max. Negotiated Rate	$1,056.00
Rate for Payer: Aetna Commercial	$847.00
Rate for Payer: Anthem POS/PPO/Traditional	$858.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$913.00
Rate for Payer: First Health Commercial	$1,045.00
Rate for Payer: Humana Commercial	$935.00
Rate for Payer: Medical Mutual Of Ohio HMO	$902.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$811.80
Rate for Payer: Molina Healthcare Benefit Exchange	$330.00
Rate for Payer: Ohio Health Choice Commercial	$968.00
Rate for Payer: Ohio Health Group HMO	$825.00
Rate for Payer: Ohio Health Group PPO Differential	$880.00
Rate for Payer: Ohio Health Group PPO No Differential	$957.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$759.00
Rate for Payer: PHCS Commercial	$1,056.00
Rate for Payer: United Healthcare All Payer	$968.00

OPEN TREAT. OF METACAR. DISLOC

Facility

$1,100.00

Service Code	HCPCS 26686
Hospital Charge Code	76100732
Hospital Revenue Code	761
Min. Negotiated Rate	$378.29
Max. Negotiated Rate	$4,197.13
Rate for Payer: Aetna Commercial	$847.00
Rate for Payer: Anthem Medicaid	$378.29
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$858.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$913.00
Rate for Payer: First Health Commercial	$1,045.00
Rate for Payer: Humana Commercial	$935.00
Rate for Payer: Humana KY Medicaid	$378.29
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$382.14
Rate for Payer: Medical Mutual Of Ohio HMO	$902.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$811.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$385.88
Rate for Payer: Ohio Health Choice Commercial	$968.00
Rate for Payer: Ohio Health Group HMO	$825.00
Rate for Payer: Ohio Health Group PPO Differential	$880.00
Rate for Payer: Ohio Health Group PPO No Differential	$957.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$759.00
Rate for Payer: PHCS Commercial	$1,056.00
Rate for Payer: United Healthcare All Payer	$968.00

OPEN TREAT. OF METACAR. DISLOC

Professional

Both

$1,100.00

Service Code	HCPCS 26686
Hospital Charge Code	76100732
Hospital Revenue Code	761
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$982.20
Rate for Payer: Aetna Commercial	$894.49
Rate for Payer: Ambetter Exchange	$595.34
Rate for Payer: Anthem Medicaid	$414.01
Rate for Payer: Buckeye Individual/Medicaid	$595.34
Rate for Payer: Buckeye Medicare Advantage	$595.34
Rate for Payer: CareSource Just4Me Medicare	$714.41
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$982.20
Rate for Payer: Healthspan PPO	$810.22
Rate for Payer: Humana Medicaid	$414.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$766.11
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$595.34
Rate for Payer: Molina Healthcare Benefit Exchange	$595.34
Rate for Payer: Molina Healthcare CHIP/Medicaid	$422.29
Rate for Payer: Molina Healthcare Passport	$414.01
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$773.94
Rate for Payer: UHCCP Medicaid	$385.00
Rate for Payer: Wellcare CHIP/Medicaid	$418.15
Rate for Payer: Wellcare Medicare Advantage	$595.34

Know your out-of-pocket cost for care.

All Charges