Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA (OTHER THAN LOCAL)

Facility

$4,112.95

Service Code	CPT 57415
Hospital Revenue Code	360
Min. Negotiated Rate	$2,937.82
Max. Negotiated Rate	$4,112.95
Rate for Payer: Anthem Medicare Advantage/PPO	$2,937.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,112.95
Rate for Payer: CareSource Just4Me Medicare	$3,966.06
Rate for Payer: Humana Medicare Advantage	$2,937.82
Rate for Payer: Molina Healthcare Benefit Exchange	$3,525.38

REMOVAL OF IMPLANT

Professional

Both

$5,366.00

Service Code	HCPCS 20670
Hospital Charge Code	76100349
Hospital Revenue Code	761
Min. Negotiated Rate	$72.11
Max. Negotiated Rate	$3,219.60
Rate for Payer: Aetna Commercial	$216.80
Rate for Payer: Ambetter Exchange	$136.51
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$77.53
Rate for Payer: Anthem Medicaid	$72.11
Rate for Payer: Buckeye Individual/Medicaid	$136.51
Rate for Payer: Buckeye Medicare Advantage	$136.51
Rate for Payer: CareSource Just4Me Medicare	$163.81
Rate for Payer: Cash Price	$2,683.00
Rate for Payer: Cash Price	$2,683.00
Rate for Payer: Cigna Commercial	$766.70
Rate for Payer: Healthspan PPO	$485.31
Rate for Payer: Humana Medicaid	$72.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$182.39
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$136.51
Rate for Payer: Molina Healthcare Benefit Exchange	$136.51
Rate for Payer: Molina Healthcare CHIP/Medicaid	$73.55
Rate for Payer: Molina Healthcare Passport	$72.11
Rate for Payer: Multiplan PHCS	$3,219.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$177.46
Rate for Payer: UHCCP Medicaid	$81.41
Rate for Payer: Wellcare CHIP/Medicaid	$72.83
Rate for Payer: Wellcare Medicare Advantage	$136.51

REMOVAL OF IMPLANT

Facility

$5,366.00

Service Code	HCPCS 20670
Hospital Charge Code	76100349
Hospital Revenue Code	761
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$5,151.36
Rate for Payer: Aetna Commercial	$4,131.82
Rate for Payer: Anthem Medicaid	$1,845.37
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Anthem POS/PPO/Traditional	$4,185.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Cash Price	$2,683.00
Rate for Payer: Cash Price	$2,683.00
Rate for Payer: Cigna Commercial	$4,453.78
Rate for Payer: First Health Commercial	$5,097.70
Rate for Payer: Humana Commercial	$4,561.10
Rate for Payer: Humana KY Medicaid	$1,845.37
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Kentucky WC Medicaid	$1,864.15
Rate for Payer: Medical Mutual Of Ohio HMO	$4,400.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,960.11
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48
Rate for Payer: Molina Healthcare Medicaid	$1,882.39
Rate for Payer: Ohio Health Choice Commercial	$4,722.08
Rate for Payer: Ohio Health Group HMO	$4,024.50
Rate for Payer: Ohio Health Group PPO Differential	$4,292.80
Rate for Payer: Ohio Health Group PPO No Differential	$4,668.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,702.54
Rate for Payer: PHCS Commercial	$5,151.36
Rate for Payer: United Healthcare All Payer	$4,722.08

REMOVAL OF IMPLANT

Facility

$5,366.00

Service Code	HCPCS 20670
Hospital Charge Code	76100349
Hospital Revenue Code	761
Min. Negotiated Rate	$1,609.80
Max. Negotiated Rate	$5,151.36
Rate for Payer: Aetna Commercial	$4,131.82
Rate for Payer: Anthem POS/PPO/Traditional	$4,185.48
Rate for Payer: Cash Price	$2,683.00
Rate for Payer: Cigna Commercial	$4,453.78
Rate for Payer: First Health Commercial	$5,097.70
Rate for Payer: Humana Commercial	$4,561.10
Rate for Payer: Medical Mutual Of Ohio HMO	$4,400.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,960.11
Rate for Payer: Molina Healthcare Benefit Exchange	$1,609.80
Rate for Payer: Ohio Health Choice Commercial	$4,722.08
Rate for Payer: Ohio Health Group HMO	$4,024.50
Rate for Payer: Ohio Health Group PPO Differential	$4,292.80
Rate for Payer: Ohio Health Group PPO No Differential	$4,668.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,702.54
Rate for Payer: PHCS Commercial	$5,151.36
Rate for Payer: United Healthcare All Payer	$4,722.08

REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY

Facility

$4,707.70

Service Code	CPT 33241
Hospital Revenue Code	360
Min. Negotiated Rate	$3,362.64
Max. Negotiated Rate	$4,707.70
Rate for Payer: Anthem Medicare Advantage/PPO	$3,362.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,707.70
Rate for Payer: CareSource Just4Me Medicare	$4,539.56
Rate for Payer: Humana Medicare Advantage	$3,362.64
Rate for Payer: Molina Healthcare Benefit Exchange	$4,035.17

REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM

Facility

$29,035.76

Service Code	CPT 33263
Hospital Revenue Code	360
Min. Negotiated Rate	$20,739.83
Max. Negotiated Rate	$29,035.76
Rate for Payer: Anthem Medicare Advantage/PPO	$20,739.83
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$29,035.76
Rate for Payer: CareSource Just4Me Medicare	$27,998.77
Rate for Payer: Humana Medicare Advantage	$20,739.83
Rate for Payer: Molina Healthcare Benefit Exchange	$24,887.80

REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)

Facility

$3,702.27

Service Code	CPT 20680
Hospital Revenue Code	360
Min. Negotiated Rate	$2,644.48
Max. Negotiated Rate	$3,702.27
Rate for Payer: Anthem Medicare Advantage/PPO	$2,644.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,702.27
Rate for Payer: CareSource Just4Me Medicare	$3,570.05
Rate for Payer: Humana Medicare Advantage	$2,644.48
Rate for Payer: Molina Healthcare Benefit Exchange	$3,173.38

REMOVAL OF IMPLANT FROM FINGER OR HAND

Facility

$2,095.90

Service Code	CPT 26320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

REMOVAL OF IMPLANT(P

Professional

Both

$650.00

Service Code	HCPCS 20670
Hospital Charge Code	761P0349
Hospital Revenue Code	761
Min. Negotiated Rate	$72.11
Max. Negotiated Rate	$766.70
Rate for Payer: Aetna Commercial	$216.80
Rate for Payer: Ambetter Exchange	$136.51
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$77.53
Rate for Payer: Anthem Medicaid	$72.11
Rate for Payer: Buckeye Individual/Medicaid	$136.51
Rate for Payer: Buckeye Medicare Advantage	$136.51
Rate for Payer: CareSource Just4Me Medicare	$163.81
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cigna Commercial	$766.70
Rate for Payer: Healthspan PPO	$485.31
Rate for Payer: Humana Medicaid	$72.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$182.39
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$136.51
Rate for Payer: Molina Healthcare Benefit Exchange	$136.51
Rate for Payer: Molina Healthcare CHIP/Medicaid	$73.55
Rate for Payer: Molina Healthcare Passport	$72.11
Rate for Payer: Multiplan PHCS	$390.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$177.46
Rate for Payer: UHCCP Medicaid	$81.41
Rate for Payer: Wellcare CHIP/Medicaid	$72.83
Rate for Payer: Wellcare Medicare Advantage	$136.51

REMOVAL OF IMPLANT SUPERF

Facility

$1,423.00

Hospital Charge Code	36000175
Hospital Revenue Code	360
Min. Negotiated Rate	$426.90
Max. Negotiated Rate	$1,366.08
Rate for Payer: Aetna Commercial	$1,095.71
Rate for Payer: Anthem POS/PPO/Traditional	$1,109.94
Rate for Payer: Cash Price	$711.50
Rate for Payer: Cigna Commercial	$1,181.09
Rate for Payer: First Health Commercial	$1,351.85
Rate for Payer: Humana Commercial	$1,209.55
Rate for Payer: Medical Mutual Of Ohio HMO	$1,166.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,050.17
Rate for Payer: Molina Healthcare Benefit Exchange	$426.90
Rate for Payer: Ohio Health Choice Commercial	$1,252.24
Rate for Payer: Ohio Health Group HMO	$1,067.25
Rate for Payer: Ohio Health Group PPO Differential	$1,138.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,238.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$981.87
Rate for Payer: PHCS Commercial	$1,366.08
Rate for Payer: United Healthcare All Payer	$1,252.24

REMOVAL OF IMPLANT SUPERF

Facility

$1,423.00

Hospital Charge Code	36000175
Hospital Revenue Code	360
Min. Negotiated Rate	$426.90
Max. Negotiated Rate	$1,366.08
Rate for Payer: Aetna Commercial	$1,095.71
Rate for Payer: Anthem Medicaid	$489.37
Rate for Payer: Anthem POS/PPO/Traditional	$1,109.94
Rate for Payer: Cash Price	$711.50
Rate for Payer: Cigna Commercial	$1,181.09
Rate for Payer: First Health Commercial	$1,351.85
Rate for Payer: Humana Commercial	$1,209.55
Rate for Payer: Humana KY Medicaid	$489.37
Rate for Payer: Kentucky WC Medicaid	$494.35
Rate for Payer: Medical Mutual Of Ohio HMO	$1,166.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,050.17
Rate for Payer: Molina Healthcare Benefit Exchange	$426.90
Rate for Payer: Molina Healthcare Medicaid	$499.19
Rate for Payer: Ohio Health Choice Commercial	$1,252.24
Rate for Payer: Ohio Health Group HMO	$1,067.25
Rate for Payer: Ohio Health Group PPO Differential	$1,138.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,238.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$981.87
Rate for Payer: PHCS Commercial	$1,366.08
Rate for Payer: United Healthcare All Payer	$1,252.24

REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) (SEPARATE PROCEDURE)

Facility

$2,095.90

Service Code	CPT 20670
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

REMOVAL OF IMPLANT(T

Facility

$4,716.00

Service Code	HCPCS 20670
Hospital Charge Code	761T0349
Hospital Revenue Code	761
Min. Negotiated Rate	$1,414.80
Max. Negotiated Rate	$4,527.36
Rate for Payer: Aetna Commercial	$3,631.32
Rate for Payer: Anthem POS/PPO/Traditional	$3,678.48
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cigna Commercial	$3,914.28
Rate for Payer: First Health Commercial	$4,480.20
Rate for Payer: Humana Commercial	$4,008.60
Rate for Payer: Medical Mutual Of Ohio HMO	$3,867.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,480.41
Rate for Payer: Molina Healthcare Benefit Exchange	$1,414.80
Rate for Payer: Ohio Health Choice Commercial	$4,150.08
Rate for Payer: Ohio Health Group HMO	$3,537.00
Rate for Payer: Ohio Health Group PPO Differential	$3,772.80
Rate for Payer: Ohio Health Group PPO No Differential	$4,102.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,254.04
Rate for Payer: PHCS Commercial	$4,527.36
Rate for Payer: United Healthcare All Payer	$4,150.08

REMOVAL OF IMPLANT(T

Facility

$4,716.00

Service Code	HCPCS 20670
Hospital Charge Code	761T0349
Hospital Revenue Code	761
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$4,527.36
Rate for Payer: Aetna Commercial	$3,631.32
Rate for Payer: Anthem Medicaid	$1,621.83
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Anthem POS/PPO/Traditional	$3,678.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cigna Commercial	$3,914.28
Rate for Payer: First Health Commercial	$4,480.20
Rate for Payer: Humana Commercial	$4,008.60
Rate for Payer: Humana KY Medicaid	$1,621.83
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Kentucky WC Medicaid	$1,638.34
Rate for Payer: Medical Mutual Of Ohio HMO	$3,867.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,480.41
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48
Rate for Payer: Molina Healthcare Medicaid	$1,654.37
Rate for Payer: Ohio Health Choice Commercial	$4,150.08
Rate for Payer: Ohio Health Group HMO	$3,537.00
Rate for Payer: Ohio Health Group PPO Differential	$3,772.80
Rate for Payer: Ohio Health Group PPO No Differential	$4,102.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,254.04
Rate for Payer: PHCS Commercial	$4,527.36
Rate for Payer: United Healthcare All Payer	$4,150.08

REMOVAL OF IMP W/CAPSULECTOMY

Professional

Both

$1,250.00

Hospital Charge Code	22200047
Hospital Revenue Code	222
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$875.00
Rate for Payer: Cash Price	$625.00
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

REMOVAL OF IMP W/CAPSULECTOMY

Facility

$1,250.00

Hospital Charge Code	22200047
Hospital Revenue Code	222
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$962.50
Rate for Payer: Anthem Medicaid	$429.88
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: Humana KY Medicaid	$429.88
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	$375.00
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	$1,000.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,087.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$862.50
Rate for Payer: PHCS Commercial	$1,200.00
Rate for Payer: United Healthcare All Payer	$1,100.00

REMOVAL OF IMP W/CAPSULECTOMY

Facility

$1,250.00

Hospital Charge Code	22200047
Hospital Revenue Code	222
Min. Negotiated Rate	$375.00
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	$1,000.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,087.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$862.50
Rate for Payer: PHCS Commercial	$1,200.00
Rate for Payer: United Healthcare All Payer	$1,100.00

REMOVAL OF INTACT BREAST IMPLANT

Facility

$4,953.45

Service Code	CPT 19328
Hospital Revenue Code	360
Min. Negotiated Rate	$3,538.18
Max. Negotiated Rate	$4,953.45
Rate for Payer: Anthem Medicare Advantage/PPO	$3,538.18
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,953.45
Rate for Payer: CareSource Just4Me Medicare	$4,776.54
Rate for Payer: Humana Medicare Advantage	$3,538.18
Rate for Payer: Molina Healthcare Benefit Exchange	$4,245.82

REMOVAL OF INTRAUTERINE DEVICE (IUD)

Facility

$393.50

Service Code	CPT 58301
Hospital Revenue Code	360
Min. Negotiated Rate	$281.07
Max. Negotiated Rate	$393.50
Rate for Payer: Anthem Medicare Advantage/PPO	$281.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$393.50
Rate for Payer: CareSource Just4Me Medicare	$379.44
Rate for Payer: Humana Medicare Advantage	$281.07
Rate for Payer: Molina Healthcare Benefit Exchange	$337.28

REMOVAL OF KIDNEY & URETER

Professional

Both

$1,300.00

Service Code	HCPCS 50234
Hospital Charge Code	76102821
Hospital Revenue Code	761
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$2,124.01
Rate for Payer: Aetna Commercial	$2,124.01
Rate for Payer: Ambetter Exchange	$1,227.98
Rate for Payer: Anthem Medicaid	$1,106.12
Rate for Payer: Buckeye Individual/Medicaid	$1,227.98
Rate for Payer: Buckeye Medicare Advantage	$1,227.98
Rate for Payer: CareSource Just4Me Medicare	$1,473.58
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$1,894.90
Rate for Payer: Healthspan PPO	$1,698.34
Rate for Payer: Humana Medicaid	$1,106.12
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,776.23
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$1,227.98
Rate for Payer: Molina Healthcare Benefit Exchange	$1,227.98
Rate for Payer: Molina Healthcare CHIP/Medicaid	$1,128.24
Rate for Payer: Molina Healthcare Passport	$1,106.12
Rate for Payer: Multiplan PHCS	$780.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,596.37
Rate for Payer: UHCCP Medicaid	$455.00
Rate for Payer: Wellcare CHIP/Medicaid	$1,117.18
Rate for Payer: Wellcare Medicare Advantage	$1,227.98

REMOVAL OF KIDNEY & URETER

Facility

$1,300.00

Service Code	HCPCS 50234
Hospital Charge Code	76102821
Hospital Revenue Code	761
Min. Negotiated Rate	$390.00
Max. Negotiated Rate	$1,248.00
Rate for Payer: Aetna Commercial	$1,001.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,014.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$1,079.00
Rate for Payer: First Health Commercial	$1,235.00
Rate for Payer: Humana Commercial	$1,105.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,066.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$959.40
Rate for Payer: Molina Healthcare Benefit Exchange	$390.00
Rate for Payer: Ohio Health Choice Commercial	$1,144.00
Rate for Payer: Ohio Health Group HMO	$975.00
Rate for Payer: Ohio Health Group PPO Differential	$1,040.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,131.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$897.00
Rate for Payer: PHCS Commercial	$1,248.00
Rate for Payer: United Healthcare All Payer	$1,144.00

REMOVAL OF KIDNEY & URETER

Facility

$1,300.00

Service Code	HCPCS 50234
Hospital Charge Code	76102821
Hospital Revenue Code	761
Min. Negotiated Rate	$390.00
Max. Negotiated Rate	$1,248.00
Rate for Payer: Aetna Commercial	$1,001.00
Rate for Payer: Anthem Medicaid	$447.07
Rate for Payer: Anthem POS/PPO/Traditional	$1,014.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$1,079.00
Rate for Payer: First Health Commercial	$1,235.00
Rate for Payer: Humana Commercial	$1,105.00
Rate for Payer: Humana KY Medicaid	$447.07
Rate for Payer: Kentucky WC Medicaid	$451.62
Rate for Payer: Medical Mutual Of Ohio HMO	$1,066.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$959.40
Rate for Payer: Molina Healthcare Benefit Exchange	$390.00
Rate for Payer: Molina Healthcare Medicaid	$456.04
Rate for Payer: Ohio Health Choice Commercial	$1,144.00
Rate for Payer: Ohio Health Group HMO	$975.00
Rate for Payer: Ohio Health Group PPO Differential	$1,040.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,131.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$897.00
Rate for Payer: PHCS Commercial	$1,248.00
Rate for Payer: United Healthcare All Payer	$1,144.00

REMOVAL OF KNEECAP

Facility

$1,640.00

Service Code	HCPCS 27350
Hospital Charge Code	76100823
Hospital Revenue Code	761
Min. Negotiated Rate	$492.00
Max. Negotiated Rate	$1,574.40
Rate for Payer: Aetna Commercial	$1,262.80
Rate for Payer: Anthem POS/PPO/Traditional	$1,279.20
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cigna Commercial	$1,361.20
Rate for Payer: First Health Commercial	$1,558.00
Rate for Payer: Humana Commercial	$1,394.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,344.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,210.32
Rate for Payer: Molina Healthcare Benefit Exchange	$492.00
Rate for Payer: Ohio Health Choice Commercial	$1,443.20
Rate for Payer: Ohio Health Group HMO	$1,230.00
Rate for Payer: Ohio Health Group PPO Differential	$1,312.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,426.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,131.60
Rate for Payer: PHCS Commercial	$1,574.40
Rate for Payer: United Healthcare All Payer	$1,443.20

REMOVAL OF KNEECAP

Facility

$1,640.00

Service Code	HCPCS 27350
Hospital Charge Code	76100823
Hospital Revenue Code	761
Min. Negotiated Rate	$564.00
Max. Negotiated Rate	$9,240.92
Rate for Payer: Aetna Commercial	$1,262.80
Rate for Payer: Anthem Medicaid	$564.00
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Anthem POS/PPO/Traditional	$1,279.20
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	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cigna Commercial	$1,361.20
Rate for Payer: First Health Commercial	$1,558.00
Rate for Payer: Humana Commercial	$1,394.00
Rate for Payer: Humana KY Medicaid	$564.00
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Kentucky WC Medicaid	$569.74
Rate for Payer: Medical Mutual Of Ohio HMO	$1,344.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,210.32
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79
Rate for Payer: Molina Healthcare Medicaid	$575.31
Rate for Payer: Ohio Health Choice Commercial	$1,443.20
Rate for Payer: Ohio Health Group HMO	$1,230.00
Rate for Payer: Ohio Health Group PPO Differential	$1,312.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,426.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,131.60
Rate for Payer: PHCS Commercial	$1,574.40
Rate for Payer: United Healthcare All Payer	$1,443.20

REMOVAL OF KNEECAP

Professional

Both

$1,640.00

Service Code	HCPCS 27350
Hospital Charge Code	76100823
Hospital Revenue Code	761
Min. Negotiated Rate	$509.69
Max. Negotiated Rate	$1,039.87
Rate for Payer: Aetna Commercial	$948.74
Rate for Payer: Ambetter Exchange	$624.98
Rate for Payer: Anthem Medicaid	$509.69
Rate for Payer: Buckeye Individual/Medicaid	$624.98
Rate for Payer: Buckeye Medicare Advantage	$624.98
Rate for Payer: CareSource Just4Me Medicare	$749.98
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cigna Commercial	$1,039.87
Rate for Payer: Healthspan PPO	$859.36
Rate for Payer: Humana Medicaid	$509.69
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$804.10
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$624.98
Rate for Payer: Molina Healthcare Benefit Exchange	$624.98
Rate for Payer: Molina Healthcare CHIP/Medicaid	$519.88
Rate for Payer: Molina Healthcare Passport	$509.69
Rate for Payer: Multiplan PHCS	$984.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$812.47
Rate for Payer: UHCCP Medicaid	$574.00
Rate for Payer: Wellcare CHIP/Medicaid	$514.79
Rate for Payer: Wellcare Medicare Advantage	$624.98

Know your out-of-pocket cost for care.

All Charges