Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL

Facility

$8,279.85

Service Code	CPT 63650
Hospital Revenue Code	360
Min. Negotiated Rate	$5,914.18
Max. Negotiated Rate	$8,279.85
Rate for Payer: Anthem Medicare Advantage/PPO	$5,914.18
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,279.85
Rate for Payer: CareSource Just4Me Medicare	$7,984.14
Rate for Payer: Humana Medicare Advantage	$5,914.18
Rate for Payer: Molina Healthcare Benefit Exchange	$7,097.02

PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED

Facility

$8,279.85

Service Code	CPT 64561
Hospital Revenue Code	360
Min. Negotiated Rate	$5,914.18
Max. Negotiated Rate	$8,279.85
Rate for Payer: Anthem Medicare Advantage/PPO	$5,914.18
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,279.85
Rate for Payer: CareSource Just4Me Medicare	$7,984.14
Rate for Payer: Humana Medicare Advantage	$5,914.18
Rate for Payer: Molina Healthcare Benefit Exchange	$7,097.02

PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)

Facility

$11,152.93

Service Code	CPT 50081
Hospital Revenue Code	360
Min. Negotiated Rate	$7,966.38
Max. Negotiated Rate	$11,152.93
Rate for Payer: Anthem Medicare Advantage/PPO	$7,966.38
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,152.93
Rate for Payer: CareSource Just4Me Medicare	$10,754.61
Rate for Payer: Humana Medicare Advantage	$7,966.38
Rate for Payer: Molina Healthcare Benefit Exchange	$9,559.66

PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)

Facility

$11,152.93

Service Code	CPT 50080
Hospital Revenue Code	360
Min. Negotiated Rate	$7,966.38
Max. Negotiated Rate	$11,152.93
Rate for Payer: Anthem Medicare Advantage/PPO	$7,966.38
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,152.93
Rate for Payer: CareSource Just4Me Medicare	$10,754.61
Rate for Payer: Humana Medicare Advantage	$7,966.38
Rate for Payer: Molina Healthcare Benefit Exchange	$9,559.66

PERCUTANEOUS SKELETAL FIXATION OF CALCANEAL FRACTURE, WITH MANIPULATION

Facility

$8,661.10

Service Code	CPT 28406
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, EACH

Facility

$3,918.70

Service Code	CPT 26756
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARATION

Facility

$3,918.70

Service Code	CPT 25606
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE

Facility

$3,918.70

Service Code	CPT 26608
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH MANIPULATION, EACH

Facility

$3,918.70

Service Code	CPT 28476
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION

Facility

$3,918.70

Service Code	CPT 28636
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH

Facility

$3,918.70

Service Code	CPT 26727
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS CIRCUIT

Facility

$21,228.97

Service Code	CPT 36906
Hospital Revenue Code	481
Min. Negotiated Rate	$15,163.55
Max. Negotiated Rate	$21,228.97
Rate for Payer: Anthem Medicare Advantage/PPO	$15,163.55
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$21,228.97
Rate for Payer: CareSource Just4Me Medicare	$20,470.79
Rate for Payer: Humana Medicare Advantage	$15,163.55
Rate for Payer: Molina Healthcare Benefit Exchange	$18,196.26

PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY

Facility

$13,318.61

Service Code	CPT 36905
Hospital Revenue Code	481
Min. Negotiated Rate	$9,513.29
Max. Negotiated Rate	$13,318.61
Rate for Payer: Anthem Medicare Advantage/PPO	$9,513.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,318.61
Rate for Payer: CareSource Just4Me Medicare	$12,842.94
Rate for Payer: Humana Medicare Advantage	$9,513.29
Rate for Payer: Molina Healthcare Benefit Exchange	$11,415.95

PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR

Facility

$8,661.10

Service Code	CPT 22514
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

Facility

$8,661.10

Service Code	CPT 22513
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

PERCUT FIX CARP SCAPHOID/WRIST

Facility

$1,235.00

Service Code	HCPCS 25999
Hospital Charge Code	76102923
Hospital Revenue Code	761
Min. Negotiated Rate	$160.55
Max. Negotiated Rate	$1,185.60
Rate for Payer: Aetna Commercial	$950.95
Rate for Payer: Anthem POS/PPO/Traditional	$963.30
Rate for Payer: Cash Price	$617.50
Rate for Payer: Cigna Commercial	$1,025.05
Rate for Payer: First Health Commercial	$1,173.25
Rate for Payer: Humana Commercial	$1,049.75
Rate for Payer: Medical Mutual Of Ohio HMO	$1,012.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$911.43
Rate for Payer: Molina Healthcare Benefit Exchange	$370.50
Rate for Payer: Ohio Health Choice Commercial	$1,086.80
Rate for Payer: Ohio Health Group HMO	$926.25
Rate for Payer: Ohio Health Group PPO Differential	$247.00
Rate for Payer: Ohio Health Group PPO No Differential	$160.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$382.85
Rate for Payer: PHCS Commercial	$1,185.60
Rate for Payer: United Healthcare All Payer	$1,086.80

PERCUT FIX CARP SCAPHOID/WRIST

Facility

$1,235.00

Service Code	HCPCS 25999
Hospital Charge Code	76102923
Hospital Revenue Code	761
Min. Negotiated Rate	$160.55
Max. Negotiated Rate	$1,185.60
Rate for Payer: Aetna Commercial	$950.95
Rate for Payer: Anthem Medicaid	$424.72
Rate for Payer: Anthem Medicare Advantage/PPO	$203.93
Rate for Payer: Anthem POS/PPO/Traditional	$963.30
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$285.50
Rate for Payer: CareSource Just4Me Medicare	$275.31
Rate for Payer: Cash Price	$617.50
Rate for Payer: Cash Price	$617.50
Rate for Payer: Cigna Commercial	$1,025.05
Rate for Payer: First Health Commercial	$1,173.25
Rate for Payer: Humana Commercial	$1,049.75
Rate for Payer: Humana KY Medicaid	$424.72
Rate for Payer: Humana Medicare Advantage	$203.93
Rate for Payer: Kentucky WC Medicaid	$429.04
Rate for Payer: Medical Mutual Of Ohio HMO	$1,012.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$911.43
Rate for Payer: Molina Healthcare Benefit Exchange	$244.72
Rate for Payer: Molina Healthcare Medicaid	$433.24
Rate for Payer: Ohio Health Choice Commercial	$1,086.80
Rate for Payer: Ohio Health Group HMO	$926.25
Rate for Payer: Ohio Health Group PPO Differential	$247.00
Rate for Payer: Ohio Health Group PPO No Differential	$160.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$382.85
Rate for Payer: PHCS Commercial	$1,185.60
Rate for Payer: United Healthcare All Payer	$1,086.80

PERCUT FIX CARP SCAPHOID/WRIST

Professional

Both

$1,235.00

Service Code	HCPCS 25999
Hospital Charge Code	76102923
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,235.00
Rate for Payer: Buckeye Medicare Advantage	$1,235.00
Rate for Payer: Cash Price	$617.50
Rate for Payer: Cash Price	$617.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$741.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$864.50
Rate for Payer: UHCCP Medicaid	$432.25

PERCUT NEEDLE WIRE/STENT O2

Professional

Both

$1,100.00

Service Code	HCPCS 31730
Hospital Charge Code	41000062
Hospital Revenue Code	410
Min. Negotiated Rate	$101.31
Max. Negotiated Rate	$1,100.00
Rate for Payer: Aetna Commercial	$243.57
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$101.31
Rate for Payer: Anthem Medicaid	$155.47
Rate for Payer: Buckeye Medicare Advantage	$1,100.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$220.48
Rate for Payer: Healthspan PPO	$1,020.67
Rate for Payer: Humana Medicaid	$155.47
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$194.25
Rate for Payer: Molina Healthcare CHIP/Medicaid	$158.58
Rate for Payer: Molina Healthcare Passport	$155.47
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$770.00
Rate for Payer: UHCCP Medicaid	$106.38
Rate for Payer: Wellcare CHIP/Medicaid	$157.02

PERCUT NEEDLE WIRE/STENT O2(P

Professional

Both

$1,100.00

Service Code	HCPCS 31730
Hospital Charge Code	410P0062
Hospital Revenue Code	410
Min. Negotiated Rate	$101.31
Max. Negotiated Rate	$1,100.00
Rate for Payer: Aetna Commercial	$243.57
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$101.31
Rate for Payer: Anthem Medicaid	$155.47
Rate for Payer: Buckeye Medicare Advantage	$1,100.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$220.48
Rate for Payer: Healthspan PPO	$1,020.67
Rate for Payer: Humana Medicaid	$155.47
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$194.25
Rate for Payer: Molina Healthcare CHIP/Medicaid	$158.58
Rate for Payer: Molina Healthcare Passport	$155.47
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$770.00
Rate for Payer: UHCCP Medicaid	$106.38
Rate for Payer: Wellcare CHIP/Medicaid	$157.02

PERFCTA TI FEM STEM SZ10.5 STD

Facility

$8,640.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

PERFCTA TI FEM STEM SZ10.5 STD

Facility

$8,640.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem Medicaid	$2,971.30
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Humana KY Medicaid	$2,971.30
Rate for Payer: Kentucky WC Medicaid	$3,001.54
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Molina Healthcare Medicaid	$3,030.91
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

PERFCTA TI FEM STEM SZ12.0 STD

Facility

$8,640.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

PERFCTA TI FEM STEM SZ12.0 STD

Facility

$8,640.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem Medicaid	$2,971.30
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Humana KY Medicaid	$2,971.30
Rate for Payer: Kentucky WC Medicaid	$3,001.54
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Molina Healthcare Medicaid	$3,030.91
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

PERFCTA TI FEM STEM SZ13.5 STD

Facility

$8,640.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

Know your out-of-pocket cost for care.

All Charges