Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE

Facility

$4,188.46

Service Code	CPT 49595
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

Facility

$6,985.45

Service Code	CPT 49592
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

Facility

$4,188.46

Service Code	CPT 49591
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE

Facility

$4,188.46

Service Code	CPT 49615
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

Facility

$6,985.45

Service Code	CPT 49614
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

Facility

$4,188.46

Service Code	CPT 49613
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR OF BICEPS TENDON

Facility

$1,875.00

Service Code	HCPCS 24340
Hospital Charge Code	76100519
Hospital Revenue Code	761
Min. Negotiated Rate	$243.75
Max. Negotiated Rate	$1,800.00
Rate for Payer: Aetna Commercial	$1,443.75
Rate for Payer: Anthem POS/PPO/Traditional	$1,462.50
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cigna Commercial	$1,556.25
Rate for Payer: First Health Commercial	$1,781.25
Rate for Payer: Humana Commercial	$1,593.75
Rate for Payer: Medical Mutual Of Ohio HMO	$1,537.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,383.75
Rate for Payer: Molina Healthcare Benefit Exchange	$562.50
Rate for Payer: Ohio Health Choice Commercial	$1,650.00
Rate for Payer: Ohio Health Group HMO	$1,406.25
Rate for Payer: Ohio Health Group PPO Differential	$375.00
Rate for Payer: Ohio Health Group PPO No Differential	$243.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$581.25
Rate for Payer: PHCS Commercial	$1,800.00
Rate for Payer: United Healthcare All Payer	$1,650.00

REPAIR OF BICEPS TENDON

Professional

Both

$1,875.00

Service Code	HCPCS 24340
Hospital Charge Code	76100519
Hospital Revenue Code	761
Min. Negotiated Rate	$437.64
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$894.57
Rate for Payer: Anthem Medicaid	$437.64
Rate for Payer: Buckeye Medicare Advantage	$1,875.00
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cigna Commercial	$985.13
Rate for Payer: Healthspan PPO	$810.29
Rate for Payer: Humana Medicaid	$437.64
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$756.65
Rate for Payer: Molina Healthcare CHIP/Medicaid	$446.39
Rate for Payer: Molina Healthcare Passport	$437.64
Rate for Payer: Multiplan PHCS	$1,125.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,312.50
Rate for Payer: UHCCP Medicaid	$656.25
Rate for Payer: Wellcare CHIP/Medicaid	$442.02

REPAIR OF BICEPS TENDON

Facility

$1,875.00

Service Code	HCPCS 24340
Hospital Charge Code	76100519
Hospital Revenue Code	761
Min. Negotiated Rate	$243.75
Max. Negotiated Rate	$8,661.10
Rate for Payer: Aetna Commercial	$1,443.75
Rate for Payer: Anthem Medicaid	$644.81
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,462.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cigna Commercial	$1,556.25
Rate for Payer: First Health Commercial	$1,781.25
Rate for Payer: Humana Commercial	$1,593.75
Rate for Payer: Humana KY Medicaid	$644.81
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Kentucky WC Medicaid	$651.38
Rate for Payer: Medical Mutual Of Ohio HMO	$1,537.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,383.75
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80
Rate for Payer: Molina Healthcare Medicaid	$657.75
Rate for Payer: Ohio Health Choice Commercial	$1,650.00
Rate for Payer: Ohio Health Group HMO	$1,406.25
Rate for Payer: Ohio Health Group PPO Differential	$375.00
Rate for Payer: Ohio Health Group PPO No Differential	$243.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$581.25
Rate for Payer: PHCS Commercial	$1,800.00
Rate for Payer: United Healthcare All Payer	$1,650.00

REPAIR OF BICEPS TENDON(P

Professional

Both

$1,875.00

Service Code	HCPCS 24340
Hospital Charge Code	761P0519
Hospital Revenue Code	761
Min. Negotiated Rate	$437.64
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$894.57
Rate for Payer: Anthem Medicaid	$437.64
Rate for Payer: Buckeye Medicare Advantage	$1,875.00
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cash Price	$937.50
Rate for Payer: Cigna Commercial	$985.13
Rate for Payer: Healthspan PPO	$810.29
Rate for Payer: Humana Medicaid	$437.64
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$756.65
Rate for Payer: Molina Healthcare CHIP/Medicaid	$446.39
Rate for Payer: Molina Healthcare Passport	$437.64
Rate for Payer: Multiplan PHCS	$1,125.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,312.50
Rate for Payer: UHCCP Medicaid	$656.25
Rate for Payer: Wellcare CHIP/Medicaid	$442.02

REPAIR OF BLADDER WOUND

Professional

Both

$2,100.00

Service Code	HCPCS 51860
Hospital Charge Code	76102076
Hospital Revenue Code	761
Min. Negotiated Rate	$554.26
Max. Negotiated Rate	$2,100.00
Rate for Payer: Aetna Commercial	$1,162.23
Rate for Payer: Anthem Medicaid	$554.26
Rate for Payer: Buckeye Medicare Advantage	$2,100.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cigna Commercial	$1,061.28
Rate for Payer: Healthspan PPO	$929.31
Rate for Payer: Humana Medicaid	$554.26
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,008.46
Rate for Payer: Molina Healthcare CHIP/Medicaid	$565.35
Rate for Payer: Molina Healthcare Passport	$554.26
Rate for Payer: Multiplan PHCS	$1,260.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,470.00
Rate for Payer: UHCCP Medicaid	$735.00
Rate for Payer: Wellcare CHIP/Medicaid	$559.80

REPAIR OF BLADDER WOUND

Facility

$2,100.00

Service Code	HCPCS 51860
Hospital Charge Code	76102076
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$2,016.00
Rate for Payer: Aetna Commercial	$1,617.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,638.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cigna Commercial	$1,743.00
Rate for Payer: First Health Commercial	$1,995.00
Rate for Payer: Humana Commercial	$1,785.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,722.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,549.80
Rate for Payer: Molina Healthcare Benefit Exchange	$630.00
Rate for Payer: Ohio Health Choice Commercial	$1,848.00
Rate for Payer: Ohio Health Group HMO	$1,575.00
Rate for Payer: Ohio Health Group PPO Differential	$420.00
Rate for Payer: Ohio Health Group PPO No Differential	$273.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$651.00
Rate for Payer: PHCS Commercial	$2,016.00
Rate for Payer: United Healthcare All Payer	$1,848.00

REPAIR OF BLADDER WOUND

Facility

$2,100.00

Service Code	HCPCS 51860
Hospital Charge Code	76102076
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$11,152.93
Rate for Payer: Aetna Commercial	$1,617.00
Rate for Payer: Anthem Medicaid	$722.19
Rate for Payer: Anthem Medicare Advantage/PPO	$7,966.38
Rate for Payer: Anthem POS/PPO/Traditional	$1,638.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,152.93
Rate for Payer: CareSource Just4Me Medicare	$10,754.61
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cigna Commercial	$1,743.00
Rate for Payer: First Health Commercial	$1,995.00
Rate for Payer: Humana Commercial	$1,785.00
Rate for Payer: Humana KY Medicaid	$722.19
Rate for Payer: Humana Medicare Advantage	$7,966.38
Rate for Payer: Kentucky WC Medicaid	$729.54
Rate for Payer: Medical Mutual Of Ohio HMO	$1,722.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,549.80
Rate for Payer: Molina Healthcare Benefit Exchange	$9,559.66
Rate for Payer: Molina Healthcare Medicaid	$736.68
Rate for Payer: Ohio Health Choice Commercial	$1,848.00
Rate for Payer: Ohio Health Group HMO	$1,575.00
Rate for Payer: Ohio Health Group PPO Differential	$420.00
Rate for Payer: Ohio Health Group PPO No Differential	$273.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$651.00
Rate for Payer: PHCS Commercial	$2,016.00
Rate for Payer: United Healthcare All Payer	$1,848.00

REPAIR OF BLADDER WOUND

Professional

Both

$2,695.00

Service Code	HCPCS 51865
Hospital Charge Code	76102077
Hospital Revenue Code	761
Min. Negotiated Rate	$735.34
Max. Negotiated Rate	$2,695.00
Rate for Payer: Aetna Commercial	$1,433.31
Rate for Payer: Anthem Medicaid	$735.34
Rate for Payer: Buckeye Medicare Advantage	$2,695.00
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$1,296.47
Rate for Payer: Healthspan PPO	$1,146.06
Rate for Payer: Humana Medicaid	$735.34
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,217.71
Rate for Payer: Molina Healthcare CHIP/Medicaid	$750.05
Rate for Payer: Molina Healthcare Passport	$735.34
Rate for Payer: Multiplan PHCS	$1,617.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,886.50
Rate for Payer: UHCCP Medicaid	$943.25
Rate for Payer: Wellcare CHIP/Medicaid	$742.69

REPAIR OF BLADDER WOUND

Facility

$2,695.00

Service Code	HCPCS 51865
Hospital Charge Code	76102077
Hospital Revenue Code	761
Min. Negotiated Rate	$350.35
Max. Negotiated Rate	$2,587.20
Rate for Payer: Aetna Commercial	$2,075.15
Rate for Payer: Anthem Medicaid	$926.81
Rate for Payer: Anthem POS/PPO/Traditional	$2,102.10
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$2,236.85
Rate for Payer: First Health Commercial	$2,560.25
Rate for Payer: Humana Commercial	$2,290.75
Rate for Payer: Humana KY Medicaid	$926.81
Rate for Payer: Kentucky WC Medicaid	$936.24
Rate for Payer: Medical Mutual Of Ohio HMO	$2,209.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,988.91
Rate for Payer: Molina Healthcare Benefit Exchange	$808.50
Rate for Payer: Molina Healthcare Medicaid	$945.41
Rate for Payer: Ohio Health Choice Commercial	$2,371.60
Rate for Payer: Ohio Health Group HMO	$2,021.25
Rate for Payer: Ohio Health Group PPO Differential	$539.00
Rate for Payer: Ohio Health Group PPO No Differential	$350.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$835.45
Rate for Payer: PHCS Commercial	$2,587.20
Rate for Payer: United Healthcare All Payer	$2,371.60

REPAIR OF BLADDER WOUND

Facility

$2,695.00

Service Code	HCPCS 51865
Hospital Charge Code	76102077
Hospital Revenue Code	761
Min. Negotiated Rate	$350.35
Max. Negotiated Rate	$2,587.20
Rate for Payer: Aetna Commercial	$2,075.15
Rate for Payer: Anthem POS/PPO/Traditional	$2,102.10
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$2,236.85
Rate for Payer: First Health Commercial	$2,560.25
Rate for Payer: Humana Commercial	$2,290.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,209.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,988.91
Rate for Payer: Molina Healthcare Benefit Exchange	$808.50
Rate for Payer: Ohio Health Choice Commercial	$2,371.60
Rate for Payer: Ohio Health Group HMO	$2,021.25
Rate for Payer: Ohio Health Group PPO Differential	$539.00
Rate for Payer: Ohio Health Group PPO No Differential	$350.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$835.45
Rate for Payer: PHCS Commercial	$2,587.20
Rate for Payer: United Healthcare All Payer	$2,371.60

REPAIR OF BLADDER WOUND(P

Professional

Both

$2,695.00

Service Code	HCPCS 51865
Hospital Charge Code	761P2077
Hospital Revenue Code	761
Min. Negotiated Rate	$735.34
Max. Negotiated Rate	$2,695.00
Rate for Payer: Aetna Commercial	$1,433.31
Rate for Payer: Anthem Medicaid	$735.34
Rate for Payer: Buckeye Medicare Advantage	$2,695.00
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cash Price	$1,347.50
Rate for Payer: Cigna Commercial	$1,296.47
Rate for Payer: Healthspan PPO	$1,146.06
Rate for Payer: Humana Medicaid	$735.34
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,217.71
Rate for Payer: Molina Healthcare CHIP/Medicaid	$750.05
Rate for Payer: Molina Healthcare Passport	$735.34
Rate for Payer: Multiplan PHCS	$1,617.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,886.50
Rate for Payer: UHCCP Medicaid	$943.25
Rate for Payer: Wellcare CHIP/Medicaid	$742.69

REPAIR OF BLADDER WOUND(P

Professional

Both

$2,100.00

Service Code	HCPCS 51860
Hospital Charge Code	761P2076
Hospital Revenue Code	761
Min. Negotiated Rate	$554.26
Max. Negotiated Rate	$2,100.00
Rate for Payer: Aetna Commercial	$1,162.23
Rate for Payer: Anthem Medicaid	$554.26
Rate for Payer: Buckeye Medicare Advantage	$2,100.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cash Price	$1,050.00
Rate for Payer: Cigna Commercial	$1,061.28
Rate for Payer: Healthspan PPO	$929.31
Rate for Payer: Humana Medicaid	$554.26
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,008.46
Rate for Payer: Molina Healthcare CHIP/Medicaid	$565.35
Rate for Payer: Molina Healthcare Passport	$554.26
Rate for Payer: Multiplan PHCS	$1,260.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,470.00
Rate for Payer: UHCCP Medicaid	$735.00
Rate for Payer: Wellcare CHIP/Medicaid	$559.80

REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH

Facility

$2,829.05

Service Code	CPT 67904
Hospital Revenue Code	360
Min. Negotiated Rate	$2,020.75
Max. Negotiated Rate	$2,829.05
Rate for Payer: Anthem Medicare Advantage/PPO	$2,020.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,829.05
Rate for Payer: CareSource Just4Me Medicare	$2,728.01
Rate for Payer: Humana Medicare Advantage	$2,020.75
Rate for Payer: Molina Healthcare Benefit Exchange	$2,424.90

REPAIR OF BOWEL BULGE

Facility

$1,250.00

Service Code	HCPCS 57268
Hospital Charge Code	76102907
Hospital Revenue Code	761
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$962.50
Rate for Payer: Anthem POS/PPO/Traditional	$975.00
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cigna Commercial	$1,037.50
Rate for Payer: First Health Commercial	$1,187.50
Rate for Payer: Humana Commercial	$1,062.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,025.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$922.50
Rate for Payer: Molina Healthcare Benefit Exchange	$375.00
Rate for Payer: Ohio Health Choice Commercial	$1,100.00
Rate for Payer: Ohio Health Group HMO	$937.50
Rate for Payer: Ohio Health Group PPO Differential	$250.00
Rate for Payer: Ohio Health Group PPO No Differential	$162.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$387.50
Rate for Payer: PHCS Commercial	$1,200.00
Rate for Payer: United Healthcare All Payer	$1,100.00

REPAIR OF BOWEL BULGE

Professional

Both

$1,250.00

Service Code	HCPCS 57268
Hospital Charge Code	76102907
Hospital Revenue Code	761
Min. Negotiated Rate	$404.91
Max. Negotiated Rate	$1,250.00
Rate for Payer: Aetna Commercial	$722.43
Rate for Payer: Anthem Medicaid	$404.91
Rate for Payer: Buckeye Medicare Advantage	$1,250.00
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cigna Commercial	$691.26
Rate for Payer: Healthspan PPO	$699.50
Rate for Payer: Humana Medicaid	$404.91
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$622.95
Rate for Payer: Molina Healthcare CHIP/Medicaid	$413.01
Rate for Payer: Molina Healthcare Passport	$404.91
Rate for Payer: Multiplan PHCS	$750.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$875.00
Rate for Payer: UHCCP Medicaid	$437.50
Rate for Payer: Wellcare CHIP/Medicaid	$408.96

REPAIR OF BOWEL BULGE

Facility

$1,250.00

Service Code	HCPCS 57268
Hospital Charge Code	76102907
Hospital Revenue Code	761
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$6,021.69
Rate for Payer: Aetna Commercial	$962.50
Rate for Payer: Anthem Medicaid	$429.88
Rate for Payer: Anthem Medicare Advantage/PPO	$4,301.21
Rate for Payer: Anthem POS/PPO/Traditional	$975.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,021.69
Rate for Payer: CareSource Just4Me Medicare	$5,806.63
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cash Price	$625.00
Rate for Payer: Cigna Commercial	$1,037.50
Rate for Payer: First Health Commercial	$1,187.50
Rate for Payer: Humana Commercial	$1,062.50
Rate for Payer: Humana KY Medicaid	$429.88
Rate for Payer: Humana Medicare Advantage	$4,301.21
Rate for Payer: Kentucky WC Medicaid	$434.25
Rate for Payer: Medical Mutual Of Ohio HMO	$1,025.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$922.50
Rate for Payer: Molina Healthcare Benefit Exchange	$5,161.45
Rate for Payer: Molina Healthcare Medicaid	$438.50
Rate for Payer: Ohio Health Choice Commercial	$1,100.00
Rate for Payer: Ohio Health Group HMO	$937.50
Rate for Payer: Ohio Health Group PPO Differential	$250.00
Rate for Payer: Ohio Health Group PPO No Differential	$162.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$387.50
Rate for Payer: PHCS Commercial	$1,200.00
Rate for Payer: United Healthcare All Payer	$1,100.00

REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)

Facility

$2,829.05

Service Code	CPT 67900
Hospital Revenue Code	360
Min. Negotiated Rate	$2,020.75
Max. Negotiated Rate	$2,829.05
Rate for Payer: Anthem Medicare Advantage/PPO	$2,020.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,829.05
Rate for Payer: CareSource Just4Me Medicare	$2,728.01
Rate for Payer: Humana Medicare Advantage	$2,020.75
Rate for Payer: Molina Healthcare Benefit Exchange	$2,424.90

REPAIR OF CHEST WALL HERNIA

Facility

$7,090.80

Service Code	HCPCS 21899
Hospital Charge Code	76100409
Hospital Revenue Code	761
Min. Negotiated Rate	$211.23
Max. Negotiated Rate	$6,807.17
Rate for Payer: Aetna Commercial	$5,459.92
Rate for Payer: Anthem Medicaid	$2,438.53
Rate for Payer: Anthem Medicare Advantage/PPO	$211.23
Rate for Payer: Anthem POS/PPO/Traditional	$5,530.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$295.72
Rate for Payer: CareSource Just4Me Medicare	$285.16
Rate for Payer: Cash Price	$3,545.40
Rate for Payer: Cash Price	$3,545.40
Rate for Payer: Cigna Commercial	$5,885.36
Rate for Payer: First Health Commercial	$6,736.26
Rate for Payer: Humana Commercial	$6,027.18
Rate for Payer: Humana KY Medicaid	$2,438.53
Rate for Payer: Humana Medicare Advantage	$211.23
Rate for Payer: Kentucky WC Medicaid	$2,463.34
Rate for Payer: Medical Mutual Of Ohio HMO	$5,814.46
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,233.01
Rate for Payer: Molina Healthcare Benefit Exchange	$253.48
Rate for Payer: Molina Healthcare Medicaid	$2,487.45
Rate for Payer: Ohio Health Choice Commercial	$6,239.90
Rate for Payer: Ohio Health Group HMO	$5,318.10
Rate for Payer: Ohio Health Group PPO Differential	$1,418.16
Rate for Payer: Ohio Health Group PPO No Differential	$921.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,198.15
Rate for Payer: PHCS Commercial	$6,807.17
Rate for Payer: United Healthcare All Payer	$6,239.90

REPAIR OF CHEST WALL HERNIA

Professional

Both

$7,090.80

Service Code	HCPCS 21899
Hospital Charge Code	76100409
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$7,090.80
Rate for Payer: Buckeye Medicare Advantage	$7,090.80
Rate for Payer: Cash Price	$3,545.40
Rate for Payer: Cash Price	$3,545.40
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$4,254.48
Rate for Payer: Ohio Health Choice Preferred Health Choice	$4,963.56
Rate for Payer: UHCCP Medicaid	$2,481.78

Know your out-of-pocket cost for care.

All Charges