Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

REUNI S CEMNT HUM STEM 12*L96

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 12*L96

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 13*L97

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 13*L97

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 14*L98

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 14*L98

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 15*L99

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 15*L99

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 7*L91

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 7*L91

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 8*L92

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 8*L92

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 9*L93

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REUNI S CEMNT HUM STEM 9*L93

Facility

$21,225.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,759.25
Max. Negotiated Rate	$20,376.00
Rate for Payer: Aetna Commercial	$16,343.25
Rate for Payer: Anthem Medicaid	$7,299.28
Rate for Payer: Anthem POS/PPO/Traditional	$16,555.50
Rate for Payer: Cash Price	$10,612.50
Rate for Payer: Cigna Commercial	$17,616.75
Rate for Payer: First Health Commercial	$20,163.75
Rate for Payer: Humana Commercial	$18,041.25
Rate for Payer: Humana KY Medicaid	$7,299.28
Rate for Payer: Kentucky WC Medicaid	$7,373.56
Rate for Payer: Medical Mutual Of Ohio HMO	$17,404.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,664.05
Rate for Payer: Molina Healthcare Benefit Exchange	$6,367.50
Rate for Payer: Molina Healthcare Medicaid	$7,445.73
Rate for Payer: Ohio Health Choice Commercial	$18,678.00
Rate for Payer: Ohio Health Group HMO	$15,918.75
Rate for Payer: Ohio Health Group PPO Differential	$4,245.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,759.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,579.75
Rate for Payer: PHCS Commercial	$20,376.00
Rate for Payer: United Healthcare All Payer	$18,678.00

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT 37225
Hospital Revenue Code	360
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT 37225
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$6,919.70

Service Code	CPT 37224
Hospital Revenue Code	360
Min. Negotiated Rate	$4,942.64
Max. Negotiated Rate	$6,919.70
Rate for Payer: Anthem Medicare Advantage/PPO	$4,942.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,919.70
Rate for Payer: CareSource Just4Me Medicare	$6,672.56
Rate for Payer: Humana Medicare Advantage	$4,942.64
Rate for Payer: Molina Healthcare Benefit Exchange	$5,931.17

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$6,919.70

Service Code	CPT 37224
Hospital Revenue Code	481
Min. Negotiated Rate	$4,942.64
Max. Negotiated Rate	$6,919.70
Rate for Payer: Anthem Medicare Advantage/PPO	$4,942.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,919.70
Rate for Payer: CareSource Just4Me Medicare	$6,672.56
Rate for Payer: Humana Medicare Advantage	$4,942.64
Rate for Payer: Molina Healthcare Benefit Exchange	$5,931.17

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT 37227
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT 37226
Hospital Revenue Code	360
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT 37226
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$6,919.70

Service Code	CPT 37220
Hospital Revenue Code	481
Min. Negotiated Rate	$4,942.64
Max. Negotiated Rate	$6,919.70
Rate for Payer: Anthem Medicare Advantage/PPO	$4,942.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,919.70
Rate for Payer: CareSource Just4Me Medicare	$6,672.56
Rate for Payer: Humana Medicare Advantage	$4,942.64
Rate for Payer: Molina Healthcare Benefit Exchange	$5,931.17

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT 37221
Hospital Revenue Code	360
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT 37221
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

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY AND TRANSLUMINAL STENT PLACEMENT(S), AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT C9767
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

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