Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

RESOLUTE ONYX 2.50*26

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*30

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*30

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*34

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.50*34

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem Medicaid	$1,418.59
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Humana KY Medicaid	$1,418.59
Rate for Payer: Kentucky WC Medicaid	$1,433.02
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Molina Healthcare Medicaid	$1,447.05
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.50*38

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*38

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*8

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.50*8

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*12

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*12

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem Medicaid	$1,418.59
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Humana KY Medicaid	$1,418.59
Rate for Payer: Kentucky WC Medicaid	$1,433.02
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Molina Healthcare Medicaid	$1,447.05
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*15

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*15

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*18

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*18

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*22

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*22

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*26

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*26

Facility

$4,737.50

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$615.88
Max. Negotiated Rate	$4,548.00
Rate for Payer: Aetna Commercial	$3,647.88
Rate for Payer: Anthem Medicaid	$1,629.23
Rate for Payer: Anthem POS/PPO/Traditional	$3,695.25
Rate for Payer: Cash Price	$2,368.75
Rate for Payer: Cigna Commercial	$3,932.12
Rate for Payer: First Health Commercial	$4,500.62
Rate for Payer: Humana Commercial	$4,026.88
Rate for Payer: Humana KY Medicaid	$1,629.23
Rate for Payer: Kentucky WC Medicaid	$1,645.81
Rate for Payer: Medical Mutual Of Ohio HMO	$3,884.75
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,496.28
Rate for Payer: Molina Healthcare Benefit Exchange	$1,421.25
Rate for Payer: Molina Healthcare Medicaid	$1,661.92
Rate for Payer: Ohio Health Choice Commercial	$4,169.00
Rate for Payer: Ohio Health Group HMO	$3,553.12
Rate for Payer: Ohio Health Group PPO Differential	$947.50
Rate for Payer: Ohio Health Group PPO No Differential	$615.88
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,468.62
Rate for Payer: PHCS Commercial	$4,548.00
Rate for Payer: United Healthcare All Payer	$4,169.00

RESOLUTE ONYX 2.75*30

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem Medicaid	$1,418.59
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Humana KY Medicaid	$1,418.59
Rate for Payer: Kentucky WC Medicaid	$1,433.02
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Molina Healthcare Medicaid	$1,447.05
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*30

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*34

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem Medicaid	$1,418.59
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Humana KY Medicaid	$1,418.59
Rate for Payer: Kentucky WC Medicaid	$1,433.02
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Molina Healthcare Medicaid	$1,447.05
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*34

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*38

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem Medicaid	$1,418.59
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Humana KY Medicaid	$1,418.59
Rate for Payer: Kentucky WC Medicaid	$1,433.02
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Molina Healthcare Medicaid	$1,447.05
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

RESOLUTE ONYX 2.75*38

Facility

$4,125.00

Service Code	HCPCS C1874
Hospital Charge Code	27000125
Hospital Revenue Code	278
Min. Negotiated Rate	$536.25
Max. Negotiated Rate	$3,960.00
Rate for Payer: Aetna Commercial	$3,176.25
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.50
Rate for Payer: Cash Price	$2,062.50
Rate for Payer: Cigna Commercial	$3,423.75
Rate for Payer: First Health Commercial	$3,918.75
Rate for Payer: Humana Commercial	$3,506.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,382.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,044.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.50
Rate for Payer: Ohio Health Choice Commercial	$3,630.00
Rate for Payer: Ohio Health Group HMO	$3,093.75
Rate for Payer: Ohio Health Group PPO Differential	$825.00
Rate for Payer: Ohio Health Group PPO No Differential	$536.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.75
Rate for Payer: PHCS Commercial	$3,960.00
Rate for Payer: United Healthcare All Payer	$3,630.00

Know your out-of-pocket cost for care.

All Charges