Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$21,228.97

Service Code	CPT C9765
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

Facility

$21,228.97

Service Code	CPT C9765
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, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT C9764
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, TIBIAL/PERONEAL ARTERY(IES); WITH INTRAVASCULAR LITHOTRIPSY AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL (S), WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT C9774
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, TIBIAL/PERONEAL ARTERY(IES), WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL (S), WHEN PERFORMED

Facility

$13,318.61

Service Code	CPT C9772
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, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$21,228.97

Service Code	CPT 37229
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, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$13,318.61

Service Code	CPT 37228
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, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY

Facility

$13,318.61

Service Code	CPT 37228
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

REVATIO 20MG TAB

Facility

$4.94

Service Code	NDC 50268071715
Hospital Charge Code	25001322
Hospital Revenue Code	637
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$4.74
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Anthem Medicaid	$1.70
Rate for Payer: Anthem POS/PPO/Traditional	$3.85
Rate for Payer: Cash Price	$2.47
Rate for Payer: Cigna Commercial	$4.10
Rate for Payer: First Health Commercial	$4.69
Rate for Payer: Humana Commercial	$4.20
Rate for Payer: Humana KY Medicaid	$1.70
Rate for Payer: Kentucky WC Medicaid	$1.72
Rate for Payer: Medical Mutual Of Ohio HMO	$4.05
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.65
Rate for Payer: Molina Healthcare Benefit Exchange	$1.48
Rate for Payer: Molina Healthcare Medicaid	$1.73
Rate for Payer: Ohio Health Choice Commercial	$4.35
Rate for Payer: Ohio Health Group HMO	$3.70
Rate for Payer: Ohio Health Group PPO Differential	$0.99
Rate for Payer: Ohio Health Group PPO No Differential	$0.64
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.53
Rate for Payer: PHCS Commercial	$4.74
Rate for Payer: United Healthcare All Payer	$4.35

REVATIO 20MG TAB

Facility

$4.94

Service Code	NDC 50268071715
Hospital Charge Code	25001322
Hospital Revenue Code	637
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$4.74
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Anthem POS/PPO/Traditional	$3.85
Rate for Payer: Cash Price	$2.47
Rate for Payer: Cigna Commercial	$4.10
Rate for Payer: First Health Commercial	$4.69
Rate for Payer: Humana Commercial	$4.20
Rate for Payer: Medical Mutual Of Ohio HMO	$4.05
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.65
Rate for Payer: Molina Healthcare Benefit Exchange	$1.48
Rate for Payer: Ohio Health Choice Commercial	$4.35
Rate for Payer: Ohio Health Group HMO	$3.70
Rate for Payer: Ohio Health Group PPO Differential	$0.99
Rate for Payer: Ohio Health Group PPO No Differential	$0.64
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.53
Rate for Payer: PHCS Commercial	$4.74
Rate for Payer: United Healthcare All Payer	$4.35

REV CMTD HUM DIAPH 150MM SZ 1

Facility

$9,163.77

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,191.29
Max. Negotiated Rate	$8,797.22
Rate for Payer: Aetna Commercial	$7,056.10
Rate for Payer: Anthem Medicaid	$3,151.42
Rate for Payer: Anthem POS/PPO/Traditional	$7,147.74
Rate for Payer: Cash Price	$4,581.89
Rate for Payer: Cigna Commercial	$7,605.93
Rate for Payer: First Health Commercial	$8,705.58
Rate for Payer: Humana Commercial	$7,789.20
Rate for Payer: Humana KY Medicaid	$3,151.42
Rate for Payer: Kentucky WC Medicaid	$3,183.49
Rate for Payer: Medical Mutual Of Ohio HMO	$7,514.29
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,762.86
Rate for Payer: Molina Healthcare Benefit Exchange	$2,749.13
Rate for Payer: Molina Healthcare Medicaid	$3,214.65
Rate for Payer: Ohio Health Choice Commercial	$8,064.12
Rate for Payer: Ohio Health Group HMO	$6,872.83
Rate for Payer: Ohio Health Group PPO Differential	$1,832.75
Rate for Payer: Ohio Health Group PPO No Differential	$1,191.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,840.77
Rate for Payer: PHCS Commercial	$8,797.22
Rate for Payer: United Healthcare All Payer	$8,064.12

REV CMTD HUM DIAPH 150MM SZ 1

Facility

$9,163.77

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,191.29
Max. Negotiated Rate	$8,797.22
Rate for Payer: Aetna Commercial	$7,056.10
Rate for Payer: Anthem POS/PPO/Traditional	$7,147.74
Rate for Payer: Cash Price	$4,581.89
Rate for Payer: Cigna Commercial	$7,605.93
Rate for Payer: First Health Commercial	$8,705.58
Rate for Payer: Humana Commercial	$7,789.20
Rate for Payer: Medical Mutual Of Ohio HMO	$7,514.29
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,762.86
Rate for Payer: Molina Healthcare Benefit Exchange	$2,749.13
Rate for Payer: Ohio Health Choice Commercial	$8,064.12
Rate for Payer: Ohio Health Group HMO	$6,872.83
Rate for Payer: Ohio Health Group PPO Differential	$1,832.75
Rate for Payer: Ohio Health Group PPO No Differential	$1,191.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,840.77
Rate for Payer: PHCS Commercial	$8,797.22
Rate for Payer: United Healthcare All Payer	$8,064.12

REV CMTD HUM DIAPH 150MM SZ 2

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV CMTD HUM DIAPH 150MM SZ 2

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem Medicaid	$2,952.47
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Humana KY Medicaid	$2,952.47
Rate for Payer: Kentucky WC Medicaid	$2,982.52
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Molina Healthcare Medicaid	$3,011.71
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV CMTD HUM DIAPH 150MM SZ 3

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV CMTD HUM DIAPH 150MM SZ 3

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem Medicaid	$2,952.47
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Humana KY Medicaid	$2,952.47
Rate for Payer: Kentucky WC Medicaid	$2,982.52
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Molina Healthcare Medicaid	$3,011.71
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV CMTD HUM DIAPH 180MM SZ 1

Facility

$9,351.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.73
Max. Negotiated Rate	$8,977.68
Rate for Payer: Aetna Commercial	$7,200.85
Rate for Payer: Anthem Medicaid	$3,216.07
Rate for Payer: Anthem POS/PPO/Traditional	$7,294.36
Rate for Payer: Cash Price	$4,675.88
Rate for Payer: Cigna Commercial	$7,761.95
Rate for Payer: First Health Commercial	$8,884.16
Rate for Payer: Humana Commercial	$7,948.99
Rate for Payer: Humana KY Medicaid	$3,216.07
Rate for Payer: Kentucky WC Medicaid	$3,248.80
Rate for Payer: Medical Mutual Of Ohio HMO	$7,668.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,901.59
Rate for Payer: Molina Healthcare Benefit Exchange	$2,805.52
Rate for Payer: Molina Healthcare Medicaid	$3,280.59
Rate for Payer: Ohio Health Choice Commercial	$8,229.54
Rate for Payer: Ohio Health Group HMO	$7,013.81
Rate for Payer: Ohio Health Group PPO Differential	$1,870.35
Rate for Payer: Ohio Health Group PPO No Differential	$1,215.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,899.04
Rate for Payer: PHCS Commercial	$8,977.68
Rate for Payer: United Healthcare All Payer	$8,229.54

REV CMTD HUM DIAPH 180MM SZ 1

Facility

$9,351.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.73
Max. Negotiated Rate	$8,977.68
Rate for Payer: Aetna Commercial	$7,200.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,294.36
Rate for Payer: Cash Price	$4,675.88
Rate for Payer: Cigna Commercial	$7,761.95
Rate for Payer: First Health Commercial	$8,884.16
Rate for Payer: Humana Commercial	$7,948.99
Rate for Payer: Medical Mutual Of Ohio HMO	$7,668.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,901.59
Rate for Payer: Molina Healthcare Benefit Exchange	$2,805.52
Rate for Payer: Ohio Health Choice Commercial	$8,229.54
Rate for Payer: Ohio Health Group HMO	$7,013.81
Rate for Payer: Ohio Health Group PPO Differential	$1,870.35
Rate for Payer: Ohio Health Group PPO No Differential	$1,215.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,899.04
Rate for Payer: PHCS Commercial	$8,977.68
Rate for Payer: United Healthcare All Payer	$8,229.54

REV CMTD HUM DIAPH 180MM SZ 2

Facility

$9,351.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.73
Max. Negotiated Rate	$8,977.68
Rate for Payer: Aetna Commercial	$7,200.85
Rate for Payer: Anthem Medicaid	$3,216.07
Rate for Payer: Anthem POS/PPO/Traditional	$7,294.36
Rate for Payer: Cash Price	$4,675.88
Rate for Payer: Cigna Commercial	$7,761.95
Rate for Payer: First Health Commercial	$8,884.16
Rate for Payer: Humana Commercial	$7,948.99
Rate for Payer: Humana KY Medicaid	$3,216.07
Rate for Payer: Kentucky WC Medicaid	$3,248.80
Rate for Payer: Medical Mutual Of Ohio HMO	$7,668.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,901.59
Rate for Payer: Molina Healthcare Benefit Exchange	$2,805.52
Rate for Payer: Molina Healthcare Medicaid	$3,280.59
Rate for Payer: Ohio Health Choice Commercial	$8,229.54
Rate for Payer: Ohio Health Group HMO	$7,013.81
Rate for Payer: Ohio Health Group PPO Differential	$1,870.35
Rate for Payer: Ohio Health Group PPO No Differential	$1,215.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,899.04
Rate for Payer: PHCS Commercial	$8,977.68
Rate for Payer: United Healthcare All Payer	$8,229.54

REV CMTD HUM DIAPH 180MM SZ 2

Facility

$9,351.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.73
Max. Negotiated Rate	$8,977.68
Rate for Payer: Aetna Commercial	$7,200.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,294.36
Rate for Payer: Cash Price	$4,675.88
Rate for Payer: Cigna Commercial	$7,761.95
Rate for Payer: First Health Commercial	$8,884.16
Rate for Payer: Humana Commercial	$7,948.99
Rate for Payer: Medical Mutual Of Ohio HMO	$7,668.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,901.59
Rate for Payer: Molina Healthcare Benefit Exchange	$2,805.52
Rate for Payer: Ohio Health Choice Commercial	$8,229.54
Rate for Payer: Ohio Health Group HMO	$7,013.81
Rate for Payer: Ohio Health Group PPO Differential	$1,870.35
Rate for Payer: Ohio Health Group PPO No Differential	$1,215.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,899.04
Rate for Payer: PHCS Commercial	$8,977.68
Rate for Payer: United Healthcare All Payer	$8,229.54

REV CMTD HUM DIAPH 180MM SZ 3

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem Medicaid	$2,952.47
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Humana KY Medicaid	$2,952.47
Rate for Payer: Kentucky WC Medicaid	$2,982.52
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Molina Healthcare Medicaid	$3,011.71
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV CMTD HUM DIAPH 180MM SZ 3

Facility

$8,585.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,116.08
Max. Negotiated Rate	$8,241.84
Rate for Payer: Aetna Commercial	$6,610.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,696.50
Rate for Payer: Cash Price	$4,292.62
Rate for Payer: Cigna Commercial	$7,125.76
Rate for Payer: First Health Commercial	$8,155.99
Rate for Payer: Humana Commercial	$7,297.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,039.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,335.91
Rate for Payer: Molina Healthcare Benefit Exchange	$2,575.58
Rate for Payer: Ohio Health Choice Commercial	$7,555.02
Rate for Payer: Ohio Health Group HMO	$6,438.94
Rate for Payer: Ohio Health Group PPO Differential	$1,717.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,116.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,661.43
Rate for Payer: PHCS Commercial	$8,241.84
Rate for Payer: United Healthcare All Payer	$7,555.02

REV COLOSTOMY; SIMPLE

Professional

Both

$850.00

Service Code	HCPCS 44340
Hospital Charge Code	76101840
Hospital Revenue Code	761
Min. Negotiated Rate	$197.94
Max. Negotiated Rate	$856.55
Rate for Payer: Aetna Commercial	$856.55
Rate for Payer: Anthem Medicaid	$197.94
Rate for Payer: Buckeye Medicare Advantage	$850.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Commercial	$785.08
Rate for Payer: Healthspan PPO	$722.34
Rate for Payer: Humana Medicaid	$197.94
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$780.22
Rate for Payer: Molina Healthcare CHIP/Medicaid	$201.90
Rate for Payer: Molina Healthcare Passport	$197.94
Rate for Payer: Multiplan PHCS	$510.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$595.00
Rate for Payer: UHCCP Medicaid	$297.50
Rate for Payer: Wellcare CHIP/Medicaid	$199.92

REV COLOSTOMY; SIMPLE

Facility

$850.00

Service Code	HCPCS 44340
Hospital Charge Code	76101840
Hospital Revenue Code	761
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$4,343.37
Rate for Payer: Aetna Commercial	$654.50
Rate for Payer: Anthem Medicaid	$292.32
Rate for Payer: Anthem Medicare Advantage/PPO	$3,102.41
Rate for Payer: Anthem POS/PPO/Traditional	$663.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,343.37
Rate for Payer: CareSource Just4Me Medicare	$4,188.25
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Commercial	$705.50
Rate for Payer: First Health Commercial	$807.50
Rate for Payer: Humana Commercial	$722.50
Rate for Payer: Humana KY Medicaid	$292.32
Rate for Payer: Humana Medicare Advantage	$3,102.41
Rate for Payer: Kentucky WC Medicaid	$295.29
Rate for Payer: Medical Mutual Of Ohio HMO	$697.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$627.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,722.89
Rate for Payer: Molina Healthcare Medicaid	$298.18
Rate for Payer: Ohio Health Choice Commercial	$748.00
Rate for Payer: Ohio Health Group HMO	$637.50
Rate for Payer: Ohio Health Group PPO Differential	$170.00
Rate for Payer: Ohio Health Group PPO No Differential	$110.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$263.50
Rate for Payer: PHCS Commercial	$816.00
Rate for Payer: United Healthcare All Payer	$748.00

REV COLOSTOMY; SIMPLE

Facility

$850.00

Service Code	HCPCS 44340
Hospital Charge Code	76101840
Hospital Revenue Code	761
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$816.00
Rate for Payer: Aetna Commercial	$654.50
Rate for Payer: Anthem POS/PPO/Traditional	$663.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Commercial	$705.50
Rate for Payer: First Health Commercial	$807.50
Rate for Payer: Humana Commercial	$722.50
Rate for Payer: Medical Mutual Of Ohio HMO	$697.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$627.30
Rate for Payer: Molina Healthcare Benefit Exchange	$255.00
Rate for Payer: Ohio Health Choice Commercial	$748.00
Rate for Payer: Ohio Health Group HMO	$637.50
Rate for Payer: Ohio Health Group PPO Differential	$170.00
Rate for Payer: Ohio Health Group PPO No Differential	$110.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$263.50
Rate for Payer: PHCS Commercial	$816.00
Rate for Payer: United Healthcare All Payer	$748.00

Know your out-of-pocket cost for care.

All Charges