Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$14,669.84

Service Code	CPT 37221
Hospital Revenue Code	481
Min. Negotiated Rate	$10,478.46
Max. Negotiated Rate	$14,669.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15

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

$23,228.31

Service Code	CPT C9767
Hospital Revenue Code	481
Min. Negotiated Rate	$16,591.65
Max. Negotiated Rate	$23,228.31
Rate for Payer: Anthem Medicare Advantage/PPO	$16,591.65
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,228.31
Rate for Payer: CareSource Just4Me Medicare	$22,398.73
Rate for Payer: Humana Medicare Advantage	$16,591.65
Rate for Payer: Molina Healthcare Benefit Exchange	$19,909.98

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

$23,228.31

Service Code	CPT C9765
Hospital Revenue Code	481
Min. Negotiated Rate	$16,591.65
Max. Negotiated Rate	$23,228.31
Rate for Payer: Anthem Medicare Advantage/PPO	$16,591.65
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,228.31
Rate for Payer: CareSource Just4Me Medicare	$22,398.73
Rate for Payer: Humana Medicare Advantage	$16,591.65
Rate for Payer: Molina Healthcare Benefit Exchange	$19,909.98

Facility

$23,228.31

Service Code	CPT C9765
Hospital Revenue Code	360
Min. Negotiated Rate	$16,591.65
Max. Negotiated Rate	$23,228.31
Rate for Payer: Anthem Medicare Advantage/PPO	$16,591.65
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,228.31
Rate for Payer: CareSource Just4Me Medicare	$22,398.73
Rate for Payer: Humana Medicare Advantage	$16,591.65
Rate for Payer: Molina Healthcare Benefit Exchange	$19,909.98

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

$14,669.84

Service Code	CPT C9764
Hospital Revenue Code	481
Min. Negotiated Rate	$10,478.46
Max. Negotiated Rate	$14,669.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15

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

Facility

$23,228.31

Service Code	CPT C9774
Hospital Revenue Code	481
Min. Negotiated Rate	$16,591.65
Max. Negotiated Rate	$23,228.31
Rate for Payer: Anthem Medicare Advantage/PPO	$16,591.65
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,228.31
Rate for Payer: CareSource Just4Me Medicare	$22,398.73
Rate for Payer: Humana Medicare Advantage	$16,591.65
Rate for Payer: Molina Healthcare Benefit Exchange	$19,909.98

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY(IES), WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL (S), WHEN PERFORMED

Facility

$14,669.84

Service Code	CPT C9772
Hospital Revenue Code	481
Min. Negotiated Rate	$10,478.46
Max. Negotiated Rate	$14,669.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15

REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED

Facility

$23,228.31

Service Code	CPT 37229
Hospital Revenue Code	481
Min. Negotiated Rate	$16,591.65
Max. Negotiated Rate	$23,228.31
Rate for Payer: Anthem Medicare Advantage/PPO	$16,591.65
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,228.31
Rate for Payer: CareSource Just4Me Medicare	$22,398.73
Rate for Payer: Humana Medicare Advantage	$16,591.65
Rate for Payer: Molina Healthcare Benefit Exchange	$19,909.98

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

Facility

$14,669.84

Service Code	CPT 37228
Hospital Revenue Code	481
Min. Negotiated Rate	$10,478.46
Max. Negotiated Rate	$14,669.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15

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

Facility

$14,669.84

Service Code	CPT 37228
Hospital Revenue Code	360
Min. Negotiated Rate	$10,478.46
Max. Negotiated Rate	$14,669.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15

REVATIO 20MG TAB

Facility

$4.94

Service Code	NDC 50268071715
Hospital Charge Code	25001322
Hospital Revenue Code	637
Min. Negotiated Rate	$1.48
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	$3.71
Rate for Payer: Ohio Health Group PPO Differential	$3.95
Rate for Payer: Ohio Health Group PPO No Differential	$4.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3.41
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	$1.48
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	$3.71
Rate for Payer: Ohio Health Group PPO Differential	$3.95
Rate for Payer: Ohio Health Group PPO No Differential	$4.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3.41
Rate for Payer: PHCS Commercial	$4.74
Rate for Payer: United Healthcare All Payer	$4.35

REV CMTD HUM DIAPH 150MM SZ 1

Facility

$9,363.77

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,809.13
Max. Negotiated Rate	$8,989.22
Rate for Payer: Aetna Commercial	$7,210.10
Rate for Payer: Anthem Medicaid	$3,220.20
Rate for Payer: Anthem POS/PPO/Traditional	$7,303.74
Rate for Payer: Cash Price	$4,681.89
Rate for Payer: Cigna Commercial	$7,771.93
Rate for Payer: First Health Commercial	$8,895.58
Rate for Payer: Humana Commercial	$7,959.20
Rate for Payer: Humana KY Medicaid	$3,220.20
Rate for Payer: Kentucky WC Medicaid	$3,252.97
Rate for Payer: Medical Mutual Of Ohio HMO	$7,678.29
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,910.46
Rate for Payer: Molina Healthcare Benefit Exchange	$2,809.13
Rate for Payer: Molina Healthcare Medicaid	$3,284.81
Rate for Payer: Ohio Health Choice Commercial	$8,240.12
Rate for Payer: Ohio Health Group HMO	$7,022.83
Rate for Payer: Ohio Health Group PPO Differential	$7,491.02
Rate for Payer: Ohio Health Group PPO No Differential	$8,146.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,461.00
Rate for Payer: PHCS Commercial	$8,989.22
Rate for Payer: United Healthcare All Payer	$8,240.12

REV CMTD HUM DIAPH 150MM SZ 1

Facility

$9,363.77

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,809.13
Max. Negotiated Rate	$8,989.22
Rate for Payer: Aetna Commercial	$7,210.10
Rate for Payer: Anthem POS/PPO/Traditional	$7,303.74
Rate for Payer: Cash Price	$4,681.89
Rate for Payer: Cigna Commercial	$7,771.93
Rate for Payer: First Health Commercial	$8,895.58
Rate for Payer: Humana Commercial	$7,959.20
Rate for Payer: Medical Mutual Of Ohio HMO	$7,678.29
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,910.46
Rate for Payer: Molina Healthcare Benefit Exchange	$2,809.13
Rate for Payer: Ohio Health Choice Commercial	$8,240.12
Rate for Payer: Ohio Health Group HMO	$7,022.83
Rate for Payer: Ohio Health Group PPO Differential	$7,491.02
Rate for Payer: Ohio Health Group PPO No Differential	$8,146.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,461.00
Rate for Payer: PHCS Commercial	$8,989.22
Rate for Payer: United Healthcare All Payer	$8,240.12

REV CMTD HUM DIAPH 150MM SZ 2

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV CMTD HUM DIAPH 150MM SZ 2

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem Medicaid	$3,021.25
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Humana KY Medicaid	$3,021.25
Rate for Payer: Kentucky WC Medicaid	$3,052.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Molina Healthcare Medicaid	$3,081.87
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV CMTD HUM DIAPH 150MM SZ 3

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem Medicaid	$3,021.25
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Humana KY Medicaid	$3,021.25
Rate for Payer: Kentucky WC Medicaid	$3,052.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Molina Healthcare Medicaid	$3,081.87
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV CMTD HUM DIAPH 150MM SZ 3

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV CMTD HUM DIAPH 180MM SZ 1

Facility

$9,551.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,865.53
Max. Negotiated Rate	$9,169.68
Rate for Payer: Aetna Commercial	$7,354.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,450.36
Rate for Payer: Cash Price	$4,775.88
Rate for Payer: Cigna Commercial	$7,927.95
Rate for Payer: First Health Commercial	$9,074.16
Rate for Payer: Humana Commercial	$8,118.99
Rate for Payer: Medical Mutual Of Ohio HMO	$7,832.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,049.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,865.53
Rate for Payer: Ohio Health Choice Commercial	$8,405.54
Rate for Payer: Ohio Health Group HMO	$7,163.81
Rate for Payer: Ohio Health Group PPO Differential	$7,641.40
Rate for Payer: Ohio Health Group PPO No Differential	$8,310.02
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,590.71
Rate for Payer: PHCS Commercial	$9,169.68
Rate for Payer: United Healthcare All Payer	$8,405.54

REV CMTD HUM DIAPH 180MM SZ 1

Facility

$9,551.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,865.53
Max. Negotiated Rate	$9,169.68
Rate for Payer: Aetna Commercial	$7,354.85
Rate for Payer: Anthem Medicaid	$3,284.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,450.36
Rate for Payer: Cash Price	$4,775.88
Rate for Payer: Cigna Commercial	$7,927.95
Rate for Payer: First Health Commercial	$9,074.16
Rate for Payer: Humana Commercial	$8,118.99
Rate for Payer: Humana KY Medicaid	$3,284.85
Rate for Payer: Kentucky WC Medicaid	$3,318.28
Rate for Payer: Medical Mutual Of Ohio HMO	$7,832.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,049.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,865.53
Rate for Payer: Molina Healthcare Medicaid	$3,350.75
Rate for Payer: Ohio Health Choice Commercial	$8,405.54
Rate for Payer: Ohio Health Group HMO	$7,163.81
Rate for Payer: Ohio Health Group PPO Differential	$7,641.40
Rate for Payer: Ohio Health Group PPO No Differential	$8,310.02
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,590.71
Rate for Payer: PHCS Commercial	$9,169.68
Rate for Payer: United Healthcare All Payer	$8,405.54

REV CMTD HUM DIAPH 180MM SZ 2

Facility

$9,551.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,865.53
Max. Negotiated Rate	$9,169.68
Rate for Payer: Aetna Commercial	$7,354.85
Rate for Payer: Anthem Medicaid	$3,284.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,450.36
Rate for Payer: Cash Price	$4,775.88
Rate for Payer: Cigna Commercial	$7,927.95
Rate for Payer: First Health Commercial	$9,074.16
Rate for Payer: Humana Commercial	$8,118.99
Rate for Payer: Humana KY Medicaid	$3,284.85
Rate for Payer: Kentucky WC Medicaid	$3,318.28
Rate for Payer: Medical Mutual Of Ohio HMO	$7,832.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,049.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,865.53
Rate for Payer: Molina Healthcare Medicaid	$3,350.75
Rate for Payer: Ohio Health Choice Commercial	$8,405.54
Rate for Payer: Ohio Health Group HMO	$7,163.81
Rate for Payer: Ohio Health Group PPO Differential	$7,641.40
Rate for Payer: Ohio Health Group PPO No Differential	$8,310.02
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,590.71
Rate for Payer: PHCS Commercial	$9,169.68
Rate for Payer: United Healthcare All Payer	$8,405.54

REV CMTD HUM DIAPH 180MM SZ 2

Facility

$9,551.75

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,865.53
Max. Negotiated Rate	$9,169.68
Rate for Payer: Aetna Commercial	$7,354.85
Rate for Payer: Anthem POS/PPO/Traditional	$7,450.36
Rate for Payer: Cash Price	$4,775.88
Rate for Payer: Cigna Commercial	$7,927.95
Rate for Payer: First Health Commercial	$9,074.16
Rate for Payer: Humana Commercial	$8,118.99
Rate for Payer: Medical Mutual Of Ohio HMO	$7,832.44
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,049.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,865.53
Rate for Payer: Ohio Health Choice Commercial	$8,405.54
Rate for Payer: Ohio Health Group HMO	$7,163.81
Rate for Payer: Ohio Health Group PPO Differential	$7,641.40
Rate for Payer: Ohio Health Group PPO No Differential	$8,310.02
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,590.71
Rate for Payer: PHCS Commercial	$9,169.68
Rate for Payer: United Healthcare All Payer	$8,405.54

REV CMTD HUM DIAPH 180MM SZ 3

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem Medicaid	$3,021.25
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Humana KY Medicaid	$3,021.25
Rate for Payer: Kentucky WC Medicaid	$3,052.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Molina Healthcare Medicaid	$3,081.87
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV CMTD HUM DIAPH 180MM SZ 3

Facility

$8,785.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.57
Max. Negotiated Rate	$8,433.84
Rate for Payer: Aetna Commercial	$6,764.64
Rate for Payer: Anthem POS/PPO/Traditional	$6,852.49
Rate for Payer: Cash Price	$4,392.62
Rate for Payer: Cigna Commercial	$7,291.76
Rate for Payer: First Health Commercial	$8,345.99
Rate for Payer: Humana Commercial	$7,467.46
Rate for Payer: Medical Mutual Of Ohio HMO	$7,203.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,483.51
Rate for Payer: Molina Healthcare Benefit Exchange	$2,635.57
Rate for Payer: Ohio Health Choice Commercial	$7,731.02
Rate for Payer: Ohio Health Group HMO	$6,588.94
Rate for Payer: Ohio Health Group PPO Differential	$7,028.20
Rate for Payer: Ohio Health Group PPO No Differential	$7,643.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,061.82
Rate for Payer: PHCS Commercial	$8,433.84
Rate for Payer: United Healthcare All Payer	$7,731.02

REV COLOSTOMY; SIMPLE

Facility

$850.00

Service Code	HCPCS 44340
Hospital Charge Code	76101840
Hospital Revenue Code	761
Min. Negotiated Rate	$292.31
Max. Negotiated Rate	$4,735.72
Rate for Payer: Aetna Commercial	$654.50
Rate for Payer: Anthem Medicaid	$292.31
Rate for Payer: Anthem Medicare Advantage/PPO	$3,382.66
Rate for Payer: Anthem POS/PPO/Traditional	$663.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,735.72
Rate for Payer: CareSource Just4Me Medicare	$4,566.59
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	$292.31
Rate for Payer: Humana Medicare Advantage	$3,382.66
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	$4,059.19
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	$680.00
Rate for Payer: Ohio Health Group PPO No Differential	$739.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$586.50
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