Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)

Facility

$4,197.13

Service Code	CPT 29875
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE

Facility

$4,197.13

Service Code	CPT 29873
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$4,197.13

Service Code	CPT 29880
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$4,197.13

Service Code	CPT 29881
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)

Facility

$4,197.13

Service Code	CPT 29882
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY KNEE W/LYSIS ADH

Facility

$2,117.00

Service Code	HCPCS 29884
Hospital Charge Code	76101105
Hospital Revenue Code	761
Min. Negotiated Rate	$728.04
Max. Negotiated Rate	$4,197.13
Rate for Payer: Aetna Commercial	$1,630.09
Rate for Payer: Anthem Medicaid	$728.04
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$1,651.26
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cigna Commercial	$1,757.11
Rate for Payer: First Health Commercial	$2,011.15
Rate for Payer: Humana Commercial	$1,799.45
Rate for Payer: Humana KY Medicaid	$728.04
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$735.45
Rate for Payer: Medical Mutual Of Ohio HMO	$1,735.94
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,562.35
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$742.64
Rate for Payer: Ohio Health Choice Commercial	$1,862.96
Rate for Payer: Ohio Health Group HMO	$1,587.75
Rate for Payer: Ohio Health Group PPO Differential	$1,693.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,841.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,460.73
Rate for Payer: PHCS Commercial	$2,032.32
Rate for Payer: United Healthcare All Payer	$1,862.96

ARTHROSCOPY KNEE W/LYSIS ADH

Professional

Both

$2,117.00

Service Code	HCPCS 29884
Hospital Charge Code	76101105
Hospital Revenue Code	761
Min. Negotiated Rate	$478.61
Max. Negotiated Rate	$1,270.20
Rate for Payer: Aetna Commercial	$895.85
Rate for Payer: Ambetter Exchange	$590.78
Rate for Payer: Anthem Medicaid	$478.61
Rate for Payer: Buckeye Individual/Medicaid	$590.78
Rate for Payer: Buckeye Medicare Advantage	$590.78
Rate for Payer: CareSource Just4Me Medicare	$708.94
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cigna Commercial	$976.29
Rate for Payer: Healthspan PPO	$811.45
Rate for Payer: Humana Medicaid	$478.61
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$767.63
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$590.78
Rate for Payer: Molina Healthcare Benefit Exchange	$590.78
Rate for Payer: Molina Healthcare CHIP/Medicaid	$488.18
Rate for Payer: Molina Healthcare Passport	$478.61
Rate for Payer: Multiplan PHCS	$1,270.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$768.01
Rate for Payer: UHCCP Medicaid	$740.95
Rate for Payer: Wellcare CHIP/Medicaid	$483.40
Rate for Payer: Wellcare Medicare Advantage	$590.78

ARTHROSCOPY KNEE W/LYSIS ADH

Facility

$2,117.00

Service Code	HCPCS 29884
Hospital Charge Code	76101105
Hospital Revenue Code	761
Min. Negotiated Rate	$635.10
Max. Negotiated Rate	$2,032.32
Rate for Payer: Aetna Commercial	$1,630.09
Rate for Payer: Anthem POS/PPO/Traditional	$1,651.26
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cigna Commercial	$1,757.11
Rate for Payer: First Health Commercial	$2,011.15
Rate for Payer: Humana Commercial	$1,799.45
Rate for Payer: Medical Mutual Of Ohio HMO	$1,735.94
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,562.35
Rate for Payer: Molina Healthcare Benefit Exchange	$635.10
Rate for Payer: Ohio Health Choice Commercial	$1,862.96
Rate for Payer: Ohio Health Group HMO	$1,587.75
Rate for Payer: Ohio Health Group PPO Differential	$1,693.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,841.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,460.73
Rate for Payer: PHCS Commercial	$2,032.32
Rate for Payer: United Healthcare All Payer	$1,862.96

ARTHROSCOPY KNEE W/LYSIS ADH(P

Professional

Both

$2,117.00

Service Code	HCPCS 29884
Hospital Charge Code	761P1105
Hospital Revenue Code	761
Min. Negotiated Rate	$478.61
Max. Negotiated Rate	$1,270.20
Rate for Payer: Aetna Commercial	$895.85
Rate for Payer: Ambetter Exchange	$590.78
Rate for Payer: Anthem Medicaid	$478.61
Rate for Payer: Buckeye Individual/Medicaid	$590.78
Rate for Payer: Buckeye Medicare Advantage	$590.78
Rate for Payer: CareSource Just4Me Medicare	$708.94
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cash Price	$1,058.50
Rate for Payer: Cigna Commercial	$976.29
Rate for Payer: Healthspan PPO	$811.45
Rate for Payer: Humana Medicaid	$478.61
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$767.63
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$590.78
Rate for Payer: Molina Healthcare Benefit Exchange	$590.78
Rate for Payer: Molina Healthcare CHIP/Medicaid	$488.18
Rate for Payer: Molina Healthcare Passport	$478.61
Rate for Payer: Multiplan PHCS	$1,270.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$768.01
Rate for Payer: UHCCP Medicaid	$740.95
Rate for Payer: Wellcare CHIP/Medicaid	$483.40
Rate for Payer: Wellcare Medicare Advantage	$590.78

ARTHROSCOPY OF JOINT

Facility

$2,300.00

Service Code	HCPCS 29999
Hospital Charge Code	76101116
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$2,208.00
Rate for Payer: Aetna Commercial	$1,771.00
Rate for Payer: Anthem Medicaid	$790.97
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$1,794.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Cigna Commercial	$1,909.00
Rate for Payer: First Health Commercial	$2,185.00
Rate for Payer: Humana Commercial	$1,955.00
Rate for Payer: Humana KY Medicaid	$790.97
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$799.02
Rate for Payer: Medical Mutual Of Ohio HMO	$1,886.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,697.40
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$806.84
Rate for Payer: Ohio Health Choice Commercial	$2,024.00
Rate for Payer: Ohio Health Group HMO	$1,725.00
Rate for Payer: Ohio Health Group PPO Differential	$1,840.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,001.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,587.00
Rate for Payer: PHCS Commercial	$2,208.00
Rate for Payer: United Healthcare All Payer	$2,024.00

ARTHROSCOPY OF JOINT

Professional

Both

$2,300.00

Service Code	HCPCS 29999
Hospital Charge Code	76101116
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,610.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,380.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,610.00
Rate for Payer: UHCCP Medicaid	$805.00

ARTHROSCOPY OF JOINT

Facility

$2,300.00

Service Code	HCPCS 29999
Hospital Charge Code	76101116
Hospital Revenue Code	761
Min. Negotiated Rate	$690.00
Max. Negotiated Rate	$2,208.00
Rate for Payer: Aetna Commercial	$1,771.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,794.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Cigna Commercial	$1,909.00
Rate for Payer: First Health Commercial	$2,185.00
Rate for Payer: Humana Commercial	$1,955.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,886.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,697.40
Rate for Payer: Molina Healthcare Benefit Exchange	$690.00
Rate for Payer: Ohio Health Choice Commercial	$2,024.00
Rate for Payer: Ohio Health Group HMO	$1,725.00
Rate for Payer: Ohio Health Group PPO Differential	$1,840.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,001.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,587.00
Rate for Payer: PHCS Commercial	$2,208.00
Rate for Payer: United Healthcare All Payer	$2,024.00

ARTHROSCOPY OF JOINT(P

Professional

Both

$2,300.00

Service Code	HCPCS 29999
Hospital Charge Code	761P1116
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,610.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Cash Price	$1,150.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,380.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,610.00
Rate for Payer: UHCCP Medicaid	$805.00

ARTHROSCOPY SHLDR AHESIOLYSI(P

Professional

Both

$1,604.00

Service Code	HCPCS 29825
Hospital Charge Code	761P1083
Hospital Revenue Code	761
Min. Negotiated Rate	$516.49
Max. Negotiated Rate	$962.40
Rate for Payer: Aetna Commercial	$860.57
Rate for Payer: Ambetter Exchange	$559.18
Rate for Payer: Anthem Medicaid	$516.49
Rate for Payer: Buckeye Individual/Medicaid	$559.18
Rate for Payer: Buckeye Medicare Advantage	$559.18
Rate for Payer: CareSource Just4Me Medicare	$671.02
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cigna Commercial	$950.31
Rate for Payer: Healthspan PPO	$779.49
Rate for Payer: Humana Medicaid	$516.49
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$724.93
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$559.18
Rate for Payer: Molina Healthcare Benefit Exchange	$559.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$526.82
Rate for Payer: Molina Healthcare Passport	$516.49
Rate for Payer: Multiplan PHCS	$962.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$726.93
Rate for Payer: UHCCP Medicaid	$561.40
Rate for Payer: Wellcare CHIP/Medicaid	$521.65
Rate for Payer: Wellcare Medicare Advantage	$559.18

ARTHROSCOPY SHLDR AHESIOLYSIS

Facility

$1,604.00

Service Code	HCPCS 29825
Hospital Charge Code	76101083
Hospital Revenue Code	761
Min. Negotiated Rate	$551.62
Max. Negotiated Rate	$4,197.13
Rate for Payer: Aetna Commercial	$1,235.08
Rate for Payer: Anthem Medicaid	$551.62
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$1,251.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cigna Commercial	$1,331.32
Rate for Payer: First Health Commercial	$1,523.80
Rate for Payer: Humana Commercial	$1,363.40
Rate for Payer: Humana KY Medicaid	$551.62
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$557.23
Rate for Payer: Medical Mutual Of Ohio HMO	$1,315.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,183.75
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$562.68
Rate for Payer: Ohio Health Choice Commercial	$1,411.52
Rate for Payer: Ohio Health Group HMO	$1,203.00
Rate for Payer: Ohio Health Group PPO Differential	$1,283.20
Rate for Payer: Ohio Health Group PPO No Differential	$1,395.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,106.76
Rate for Payer: PHCS Commercial	$1,539.84
Rate for Payer: United Healthcare All Payer	$1,411.52

ARTHROSCOPY SHLDR AHESIOLYSIS

Facility

$1,604.00

Service Code	HCPCS 29825
Hospital Charge Code	76101083
Hospital Revenue Code	761
Min. Negotiated Rate	$481.20
Max. Negotiated Rate	$1,539.84
Rate for Payer: Aetna Commercial	$1,235.08
Rate for Payer: Anthem POS/PPO/Traditional	$1,251.12
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cigna Commercial	$1,331.32
Rate for Payer: First Health Commercial	$1,523.80
Rate for Payer: Humana Commercial	$1,363.40
Rate for Payer: Medical Mutual Of Ohio HMO	$1,315.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,183.75
Rate for Payer: Molina Healthcare Benefit Exchange	$481.20
Rate for Payer: Ohio Health Choice Commercial	$1,411.52
Rate for Payer: Ohio Health Group HMO	$1,203.00
Rate for Payer: Ohio Health Group PPO Differential	$1,283.20
Rate for Payer: Ohio Health Group PPO No Differential	$1,395.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,106.76
Rate for Payer: PHCS Commercial	$1,539.84
Rate for Payer: United Healthcare All Payer	$1,411.52

ARTHROSCOPY SHLDR AHESIOLYSIS

Professional

Both

$1,604.00

Service Code	HCPCS 29825
Hospital Charge Code	76101083
Hospital Revenue Code	761
Min. Negotiated Rate	$516.49
Max. Negotiated Rate	$962.40
Rate for Payer: Aetna Commercial	$860.57
Rate for Payer: Ambetter Exchange	$559.18
Rate for Payer: Anthem Medicaid	$516.49
Rate for Payer: Buckeye Individual/Medicaid	$559.18
Rate for Payer: Buckeye Medicare Advantage	$559.18
Rate for Payer: CareSource Just4Me Medicare	$671.02
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cash Price	$802.00
Rate for Payer: Cigna Commercial	$950.31
Rate for Payer: Healthspan PPO	$779.49
Rate for Payer: Humana Medicaid	$516.49
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$724.93
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$559.18
Rate for Payer: Molina Healthcare Benefit Exchange	$559.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$526.82
Rate for Payer: Molina Healthcare Passport	$516.49
Rate for Payer: Multiplan PHCS	$962.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$726.93
Rate for Payer: UHCCP Medicaid	$561.40
Rate for Payer: Wellcare CHIP/Medicaid	$521.65
Rate for Payer: Wellcare Medicare Advantage	$559.18

ARTHROSCOPY SHLDR RMV LOOSE/FB

Facility

$1,640.00

Service Code	HCPCS 29819
Hospital Charge Code	76101077
Hospital Revenue Code	761
Min. Negotiated Rate	$564.00
Max. Negotiated Rate	$4,197.13
Rate for Payer: Aetna Commercial	$1,262.80
Rate for Payer: Anthem Medicaid	$564.00
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$1,279.20
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
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	$2,997.95
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	$3,597.54
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

ARTHROSCOPY SHLDR RMV LOOSE/FB

Professional

Both

$1,640.00

Service Code	HCPCS 29819
Hospital Charge Code	761P1077
Hospital Revenue Code	761
Min. Negotiated Rate	$508.71
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$861.64
Rate for Payer: Ambetter Exchange	$558.92
Rate for Payer: Anthem Medicaid	$508.71
Rate for Payer: Buckeye Individual/Medicaid	$558.92
Rate for Payer: Buckeye Medicare Advantage	$558.92
Rate for Payer: CareSource Just4Me Medicare	$670.70
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cigna Commercial	$951.56
Rate for Payer: Healthspan PPO	$780.46
Rate for Payer: Humana Medicaid	$508.71
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$726.57
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$558.92
Rate for Payer: Molina Healthcare Benefit Exchange	$558.92
Rate for Payer: Molina Healthcare CHIP/Medicaid	$518.88
Rate for Payer: Molina Healthcare Passport	$508.71
Rate for Payer: Multiplan PHCS	$984.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$726.60
Rate for Payer: UHCCP Medicaid	$574.00
Rate for Payer: Wellcare CHIP/Medicaid	$513.80
Rate for Payer: Wellcare Medicare Advantage	$558.92

ARTHROSCOPY SHLDR RMV LOOSE/FB

Facility

$1,640.00

Service Code	HCPCS 29819
Hospital Charge Code	76101077
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

ARTHROSCOPY SHLDR RMV LOOSE/FB

Professional

Both

$1,640.00

Service Code	HCPCS 29819
Hospital Charge Code	76101077
Hospital Revenue Code	761
Min. Negotiated Rate	$508.71
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$861.64
Rate for Payer: Ambetter Exchange	$558.92
Rate for Payer: Anthem Medicaid	$508.71
Rate for Payer: Buckeye Individual/Medicaid	$558.92
Rate for Payer: Buckeye Medicare Advantage	$558.92
Rate for Payer: CareSource Just4Me Medicare	$670.70
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cigna Commercial	$951.56
Rate for Payer: Healthspan PPO	$780.46
Rate for Payer: Humana Medicaid	$508.71
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$726.57
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$558.92
Rate for Payer: Molina Healthcare Benefit Exchange	$558.92
Rate for Payer: Molina Healthcare CHIP/Medicaid	$518.88
Rate for Payer: Molina Healthcare Passport	$508.71
Rate for Payer: Multiplan PHCS	$984.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$726.60
Rate for Payer: UHCCP Medicaid	$574.00
Rate for Payer: Wellcare CHIP/Medicaid	$513.80
Rate for Payer: Wellcare Medicare Advantage	$558.92

ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS

Facility

$9,240.92

Service Code	CPT 29828
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY

Facility

$9,240.92

Service Code	CPT 29806
Hospital Revenue Code	360
Min. Negotiated Rate	$6,600.66
Max. Negotiated Rate	$9,240.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,600.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$9,240.92
Rate for Payer: CareSource Just4Me Medicare	$8,910.89
Rate for Payer: Humana Medicare Advantage	$6,600.66
Rate for Payer: Molina Healthcare Benefit Exchange	$7,920.79

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$4,197.13

Service Code	CPT 29823
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$4,197.13

Service Code	CPT 29822
Hospital Revenue Code	360
Min. Negotiated Rate	$2,997.95
Max. Negotiated Rate	$4,197.13
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,197.13
Rate for Payer: CareSource Just4Me Medicare	$4,047.23
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54

Know your out-of-pocket cost for care.

All Charges