Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)

Facility

$4,197.13

Service Code	CPT 29824
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; REPAIR OF SLAP LESION

Facility

$9,240.92

Service Code	CPT 29807
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; SYNOVECTOMY, PARTIAL

Facility

$9,240.92

Service Code	CPT 29820
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; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION

Facility

$4,197.13

Service Code	CPT 29825
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; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY

Facility

$4,197.13

Service Code	CPT 29819
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; WITH ROTATOR CUFF REPAIR

Facility

$9,240.92

Service Code	CPT 29827
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

ARTHROSC SHLDER REMPLISSAGE

Professional

Both

$2,715.00

Service Code	HCPCS 29999
Hospital Charge Code	76102975
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,900.50
Rate for Payer: Cash Price	$1,357.50
Rate for Payer: Cash Price	$1,357.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,629.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,900.50
Rate for Payer: UHCCP Medicaid	$950.25

ARTHRO, SHLD W/SUBCHRO BLN AUG

Facility

$2,325.00

Service Code	HCPCS 29999
Hospital Charge Code	76102963
Hospital Revenue Code	761
Min. Negotiated Rate	$697.50
Max. Negotiated Rate	$2,232.00
Rate for Payer: Aetna Commercial	$1,790.25
Rate for Payer: Anthem POS/PPO/Traditional	$1,813.50
Rate for Payer: Cash Price	$1,162.50
Rate for Payer: Cigna Commercial	$1,929.75
Rate for Payer: First Health Commercial	$2,208.75
Rate for Payer: Humana Commercial	$1,976.25
Rate for Payer: Medical Mutual Of Ohio HMO	$1,906.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,715.85
Rate for Payer: Molina Healthcare Benefit Exchange	$697.50
Rate for Payer: Ohio Health Choice Commercial	$2,046.00
Rate for Payer: Ohio Health Group HMO	$1,743.75
Rate for Payer: Ohio Health Group PPO Differential	$1,860.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,022.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,604.25
Rate for Payer: PHCS Commercial	$2,232.00
Rate for Payer: United Healthcare All Payer	$2,046.00

ARTHRO, SHLD W/SUBCHRO BLN AUG

Professional

Both

$2,325.00

Service Code	HCPCS 29999
Hospital Charge Code	76102963
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,627.50
Rate for Payer: Cash Price	$1,162.50
Rate for Payer: Cash Price	$1,162.50
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$1,395.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,627.50
Rate for Payer: UHCCP Medicaid	$813.75

ARTHRO, SHLD W/SUBCHRO BLN AUG

Facility

$2,325.00

Service Code	HCPCS 29999
Hospital Charge Code	76102963
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$2,232.00
Rate for Payer: Aetna Commercial	$1,790.25
Rate for Payer: Anthem Medicaid	$799.57
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$1,813.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$1,162.50
Rate for Payer: Cash Price	$1,162.50
Rate for Payer: Cigna Commercial	$1,929.75
Rate for Payer: First Health Commercial	$2,208.75
Rate for Payer: Humana Commercial	$1,976.25
Rate for Payer: Humana KY Medicaid	$799.57
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$807.71
Rate for Payer: Medical Mutual Of Ohio HMO	$1,906.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,715.85
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$815.61
Rate for Payer: Ohio Health Choice Commercial	$2,046.00
Rate for Payer: Ohio Health Group HMO	$1,743.75
Rate for Payer: Ohio Health Group PPO Differential	$1,860.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,022.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,604.25
Rate for Payer: PHCS Commercial	$2,232.00
Rate for Payer: United Healthcare All Payer	$2,046.00

ARTHRO SP +/- INJ MAJ JNT W/US

Facility

$540.00

Service Code	HCPCS 20611
Hospital Charge Code	45000094
Hospital Revenue Code	450
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$518.40
Rate for Payer: Aetna Commercial	$415.80
Rate for Payer: Anthem POS/PPO/Traditional	$421.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$448.20
Rate for Payer: First Health Commercial	$513.00
Rate for Payer: Humana Commercial	$459.00
Rate for Payer: Medical Mutual Of Ohio HMO	$442.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$398.52
Rate for Payer: Molina Healthcare Benefit Exchange	$162.00
Rate for Payer: Ohio Health Choice Commercial	$475.20
Rate for Payer: Ohio Health Group HMO	$405.00
Rate for Payer: Ohio Health Group PPO Differential	$432.00
Rate for Payer: Ohio Health Group PPO No Differential	$469.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$372.60
Rate for Payer: PHCS Commercial	$518.40
Rate for Payer: United Healthcare All Payer	$475.20

ARTHRO SP +/- INJ MAJ JNT W/US

Facility

$540.00

Service Code	HCPCS 20611
Hospital Charge Code	45000094
Hospital Revenue Code	450
Min. Negotiated Rate	$185.71
Max. Negotiated Rate	$518.40
Rate for Payer: Aetna Commercial	$415.80
Rate for Payer: Anthem Medicaid	$185.71
Rate for Payer: Anthem Medicare Advantage/PPO	$272.75
Rate for Payer: Anthem POS/PPO/Traditional	$421.20
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$381.85
Rate for Payer: CareSource Just4Me Medicare	$368.21
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$448.20
Rate for Payer: First Health Commercial	$513.00
Rate for Payer: Humana Commercial	$459.00
Rate for Payer: Humana KY Medicaid	$185.71
Rate for Payer: Humana Medicare Advantage	$272.75
Rate for Payer: Kentucky WC Medicaid	$187.60
Rate for Payer: Medical Mutual Of Ohio HMO	$442.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$398.52
Rate for Payer: Molina Healthcare Benefit Exchange	$327.30
Rate for Payer: Molina Healthcare Medicaid	$189.43
Rate for Payer: Ohio Health Choice Commercial	$475.20
Rate for Payer: Ohio Health Group HMO	$405.00
Rate for Payer: Ohio Health Group PPO Differential	$432.00
Rate for Payer: Ohio Health Group PPO No Differential	$469.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$372.60
Rate for Payer: PHCS Commercial	$518.40
Rate for Payer: United Healthcare All Payer	$475.20

ARTHROTEC(DICLOFENAC SOD.MISO)

Facility

$10.68

Service Code	NDC 68001023106
Hospital Charge Code	25000258
Hospital Revenue Code	637
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$10.25
Rate for Payer: Aetna Commercial	$8.22
Rate for Payer: Anthem Medicaid	$3.67
Rate for Payer: Anthem POS/PPO/Traditional	$8.33
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cigna Commercial	$8.86
Rate for Payer: First Health Commercial	$10.15
Rate for Payer: Humana Commercial	$9.08
Rate for Payer: Humana KY Medicaid	$3.67
Rate for Payer: Kentucky WC Medicaid	$3.71
Rate for Payer: Medical Mutual Of Ohio HMO	$8.76
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7.88
Rate for Payer: Molina Healthcare Benefit Exchange	$3.20
Rate for Payer: Molina Healthcare Medicaid	$3.75
Rate for Payer: Ohio Health Choice Commercial	$9.40
Rate for Payer: Ohio Health Group HMO	$8.01
Rate for Payer: Ohio Health Group PPO Differential	$8.54
Rate for Payer: Ohio Health Group PPO No Differential	$9.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$7.37
Rate for Payer: PHCS Commercial	$10.25
Rate for Payer: United Healthcare All Payer	$9.40

ARTHROTEC(DICLOFENAC SOD.MISO)

Facility

$10.68

Service Code	NDC 68001023106
Hospital Charge Code	25000258
Hospital Revenue Code	637
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$10.25
Rate for Payer: Aetna Commercial	$8.22
Rate for Payer: Anthem POS/PPO/Traditional	$8.33
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cigna Commercial	$8.86
Rate for Payer: First Health Commercial	$10.15
Rate for Payer: Humana Commercial	$9.08
Rate for Payer: Medical Mutual Of Ohio HMO	$8.76
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7.88
Rate for Payer: Molina Healthcare Benefit Exchange	$3.20
Rate for Payer: Ohio Health Choice Commercial	$9.40
Rate for Payer: Ohio Health Group HMO	$8.01
Rate for Payer: Ohio Health Group PPO Differential	$8.54
Rate for Payer: Ohio Health Group PPO No Differential	$9.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$7.37
Rate for Payer: PHCS Commercial	$10.25
Rate for Payer: United Healthcare All Payer	$9.40

ARTHROTOMY, ELBOW/SYNOVECTOM(P

Professional

Both

$1,100.00

Service Code	HCPCS 24102
Hospital Charge Code	761P0507
Hospital Revenue Code	761
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$986.46
Rate for Payer: Aetna Commercial	$895.91
Rate for Payer: Ambetter Exchange	$589.94
Rate for Payer: Anthem Medicaid	$525.75
Rate for Payer: Buckeye Individual/Medicaid	$589.94
Rate for Payer: Buckeye Medicare Advantage	$589.94
Rate for Payer: CareSource Just4Me Medicare	$707.93
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$986.46
Rate for Payer: Healthspan PPO	$811.51
Rate for Payer: Humana Medicaid	$525.75
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$757.43
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$589.94
Rate for Payer: Molina Healthcare Benefit Exchange	$589.94
Rate for Payer: Molina Healthcare CHIP/Medicaid	$536.26
Rate for Payer: Molina Healthcare Passport	$525.75
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$766.92
Rate for Payer: UHCCP Medicaid	$385.00
Rate for Payer: Wellcare CHIP/Medicaid	$531.01
Rate for Payer: Wellcare Medicare Advantage	$589.94

ARTHROTOMY, ELBOW/SYNOVECTOM(T

Facility

$5,594.00

Service Code	HCPCS 24102
Hospital Charge Code	761T0507
Hospital Revenue Code	761
Min. Negotiated Rate	$1,923.78
Max. Negotiated Rate	$5,370.24
Rate for Payer: Aetna Commercial	$4,307.38
Rate for Payer: Anthem Medicaid	$1,923.78
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$4,363.32
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	$2,797.00
Rate for Payer: Cash Price	$2,797.00
Rate for Payer: Cigna Commercial	$4,643.02
Rate for Payer: First Health Commercial	$5,314.30
Rate for Payer: Humana Commercial	$4,754.90
Rate for Payer: Humana KY Medicaid	$1,923.78
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$1,943.36
Rate for Payer: Medical Mutual Of Ohio HMO	$4,587.08
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,128.37
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$1,962.38
Rate for Payer: Ohio Health Choice Commercial	$4,922.72
Rate for Payer: Ohio Health Group HMO	$4,195.50
Rate for Payer: Ohio Health Group PPO Differential	$4,475.20
Rate for Payer: Ohio Health Group PPO No Differential	$4,866.78
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,859.86
Rate for Payer: PHCS Commercial	$5,370.24
Rate for Payer: United Healthcare All Payer	$4,922.72

ARTHROTOMY, ELBOW/SYNOVECTOM(T

Facility

$5,594.00

Service Code	HCPCS 24102
Hospital Charge Code	761T0507
Hospital Revenue Code	761
Min. Negotiated Rate	$1,678.20
Max. Negotiated Rate	$5,370.24
Rate for Payer: Aetna Commercial	$4,307.38
Rate for Payer: Anthem POS/PPO/Traditional	$4,363.32
Rate for Payer: Cash Price	$2,797.00
Rate for Payer: Cigna Commercial	$4,643.02
Rate for Payer: First Health Commercial	$5,314.30
Rate for Payer: Humana Commercial	$4,754.90
Rate for Payer: Medical Mutual Of Ohio HMO	$4,587.08
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,128.37
Rate for Payer: Molina Healthcare Benefit Exchange	$1,678.20
Rate for Payer: Ohio Health Choice Commercial	$4,922.72
Rate for Payer: Ohio Health Group HMO	$4,195.50
Rate for Payer: Ohio Health Group PPO Differential	$4,475.20
Rate for Payer: Ohio Health Group PPO No Differential	$4,866.78
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,859.86
Rate for Payer: PHCS Commercial	$5,370.24
Rate for Payer: United Healthcare All Payer	$4,922.72

ARTHROTOMY, ELBOW/SYNOVECTOMY

Facility

$6,694.00

Service Code	HCPCS 24102
Hospital Charge Code	76100507
Hospital Revenue Code	761
Min. Negotiated Rate	$2,302.07
Max. Negotiated Rate	$6,426.24
Rate for Payer: Aetna Commercial	$5,154.38
Rate for Payer: Anthem Medicaid	$2,302.07
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$5,221.32
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	$3,347.00
Rate for Payer: Cash Price	$3,347.00
Rate for Payer: Cigna Commercial	$5,556.02
Rate for Payer: First Health Commercial	$6,359.30
Rate for Payer: Humana Commercial	$5,689.90
Rate for Payer: Humana KY Medicaid	$2,302.07
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$2,325.50
Rate for Payer: Medical Mutual Of Ohio HMO	$5,489.08
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,940.17
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$2,348.26
Rate for Payer: Ohio Health Choice Commercial	$5,890.72
Rate for Payer: Ohio Health Group HMO	$5,020.50
Rate for Payer: Ohio Health Group PPO Differential	$5,355.20
Rate for Payer: Ohio Health Group PPO No Differential	$5,823.78
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,618.86
Rate for Payer: PHCS Commercial	$6,426.24
Rate for Payer: United Healthcare All Payer	$5,890.72

ARTHROTOMY, ELBOW/SYNOVECTOMY

Facility

$6,694.00

Service Code	HCPCS 24102
Hospital Charge Code	76100507
Hospital Revenue Code	761
Min. Negotiated Rate	$2,008.20
Max. Negotiated Rate	$6,426.24
Rate for Payer: Aetna Commercial	$5,154.38
Rate for Payer: Anthem POS/PPO/Traditional	$5,221.32
Rate for Payer: Cash Price	$3,347.00
Rate for Payer: Cigna Commercial	$5,556.02
Rate for Payer: First Health Commercial	$6,359.30
Rate for Payer: Humana Commercial	$5,689.90
Rate for Payer: Medical Mutual Of Ohio HMO	$5,489.08
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,940.17
Rate for Payer: Molina Healthcare Benefit Exchange	$2,008.20
Rate for Payer: Ohio Health Choice Commercial	$5,890.72
Rate for Payer: Ohio Health Group HMO	$5,020.50
Rate for Payer: Ohio Health Group PPO Differential	$5,355.20
Rate for Payer: Ohio Health Group PPO No Differential	$5,823.78
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,618.86
Rate for Payer: PHCS Commercial	$6,426.24
Rate for Payer: United Healthcare All Payer	$5,890.72

ARTHROTOMY, ELBOW/SYNOVECTOMY

Professional

Both

$6,694.00

Service Code	HCPCS 24102
Hospital Charge Code	76100507
Hospital Revenue Code	761
Min. Negotiated Rate	$525.75
Max. Negotiated Rate	$4,016.40
Rate for Payer: Aetna Commercial	$895.91
Rate for Payer: Ambetter Exchange	$589.94
Rate for Payer: Anthem Medicaid	$525.75
Rate for Payer: Buckeye Individual/Medicaid	$589.94
Rate for Payer: Buckeye Medicare Advantage	$589.94
Rate for Payer: CareSource Just4Me Medicare	$707.93
Rate for Payer: Cash Price	$3,347.00
Rate for Payer: Cash Price	$3,347.00
Rate for Payer: Cigna Commercial	$986.46
Rate for Payer: Healthspan PPO	$811.51
Rate for Payer: Humana Medicaid	$525.75
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$757.43
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$589.94
Rate for Payer: Molina Healthcare Benefit Exchange	$589.94
Rate for Payer: Molina Healthcare CHIP/Medicaid	$536.26
Rate for Payer: Molina Healthcare Passport	$525.75
Rate for Payer: Multiplan PHCS	$4,016.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$766.92
Rate for Payer: UHCCP Medicaid	$2,342.90
Rate for Payer: Wellcare CHIP/Medicaid	$531.01
Rate for Payer: Wellcare Medicare Advantage	$589.94

ARTHROTOMY EXP DRNGE

Facility

$560.00

Service Code	HCPCS 28020
Hospital Charge Code	76100968
Hospital Revenue Code	761
Min. Negotiated Rate	$192.58
Max. Negotiated Rate	$4,197.13
Rate for Payer: Aetna Commercial	$431.20
Rate for Payer: Anthem Medicaid	$192.58
Rate for Payer: Anthem Medicare Advantage/PPO	$2,997.95
Rate for Payer: Anthem POS/PPO/Traditional	$436.80
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	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cigna Commercial	$464.80
Rate for Payer: First Health Commercial	$532.00
Rate for Payer: Humana Commercial	$476.00
Rate for Payer: Humana KY Medicaid	$192.58
Rate for Payer: Humana Medicare Advantage	$2,997.95
Rate for Payer: Kentucky WC Medicaid	$194.54
Rate for Payer: Medical Mutual Of Ohio HMO	$459.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$413.28
Rate for Payer: Molina Healthcare Benefit Exchange	$3,597.54
Rate for Payer: Molina Healthcare Medicaid	$196.45
Rate for Payer: Ohio Health Choice Commercial	$492.80
Rate for Payer: Ohio Health Group HMO	$420.00
Rate for Payer: Ohio Health Group PPO Differential	$448.00
Rate for Payer: Ohio Health Group PPO No Differential	$487.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$386.40
Rate for Payer: PHCS Commercial	$537.60
Rate for Payer: United Healthcare All Payer	$492.80

ARTHROTOMY EXP DRNGE

Professional

Both

$560.00

Service Code	HCPCS 28020
Hospital Charge Code	76100968
Hospital Revenue Code	761
Min. Negotiated Rate	$249.34
Max. Negotiated Rate	$748.73
Rate for Payer: Aetna Commercial	$541.38
Rate for Payer: Ambetter Exchange	$343.46
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$249.34
Rate for Payer: Anthem Medicaid	$271.01
Rate for Payer: Buckeye Individual/Medicaid	$343.46
Rate for Payer: Buckeye Medicare Advantage	$343.46
Rate for Payer: CareSource Just4Me Medicare	$412.15
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cigna Commercial	$748.73
Rate for Payer: Healthspan PPO	$645.03
Rate for Payer: Humana Medicaid	$271.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$443.99
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$343.46
Rate for Payer: Molina Healthcare Benefit Exchange	$343.46
Rate for Payer: Molina Healthcare CHIP/Medicaid	$276.43
Rate for Payer: Molina Healthcare Passport	$271.01
Rate for Payer: Multiplan PHCS	$336.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$446.50
Rate for Payer: UHCCP Medicaid	$261.81
Rate for Payer: Wellcare CHIP/Medicaid	$273.72
Rate for Payer: Wellcare Medicare Advantage	$343.46

ARTHROTOMY EXP DRNGE

Facility

$560.00

Service Code	HCPCS 28020
Hospital Charge Code	76100968
Hospital Revenue Code	761
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$537.60
Rate for Payer: Aetna Commercial	$431.20
Rate for Payer: Anthem POS/PPO/Traditional	$436.80
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cigna Commercial	$464.80
Rate for Payer: First Health Commercial	$532.00
Rate for Payer: Humana Commercial	$476.00
Rate for Payer: Medical Mutual Of Ohio HMO	$459.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$413.28
Rate for Payer: Molina Healthcare Benefit Exchange	$168.00
Rate for Payer: Ohio Health Choice Commercial	$492.80
Rate for Payer: Ohio Health Group HMO	$420.00
Rate for Payer: Ohio Health Group PPO Differential	$448.00
Rate for Payer: Ohio Health Group PPO No Differential	$487.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$386.40
Rate for Payer: PHCS Commercial	$537.60
Rate for Payer: United Healthcare All Payer	$492.80

ARTHROTOMY EXP DRNGE(P

Professional

Both

$560.00

Service Code	HCPCS 28020
Hospital Charge Code	761P0968
Hospital Revenue Code	761
Min. Negotiated Rate	$249.34
Max. Negotiated Rate	$748.73
Rate for Payer: Aetna Commercial	$541.38
Rate for Payer: Ambetter Exchange	$343.46
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$249.34
Rate for Payer: Anthem Medicaid	$271.01
Rate for Payer: Buckeye Individual/Medicaid	$343.46
Rate for Payer: Buckeye Medicare Advantage	$343.46
Rate for Payer: CareSource Just4Me Medicare	$412.15
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cigna Commercial	$748.73
Rate for Payer: Healthspan PPO	$645.03
Rate for Payer: Humana Medicaid	$271.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$443.99
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$343.46
Rate for Payer: Molina Healthcare Benefit Exchange	$343.46
Rate for Payer: Molina Healthcare CHIP/Medicaid	$276.43
Rate for Payer: Molina Healthcare Passport	$271.01
Rate for Payer: Multiplan PHCS	$336.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$446.50
Rate for Payer: UHCCP Medicaid	$261.81
Rate for Payer: Wellcare CHIP/Medicaid	$273.72
Rate for Payer: Wellcare Medicare Advantage	$343.46

ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES

Facility

$4,197.13

Service Code	CPT 27331
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.

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