Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

SRA/IPL LIMTD FACLSR-PP #1 50%

Professional

Both

$319.00

Hospital Charge Code	22200337
Hospital Revenue Code	222
Min. Negotiated Rate	$111.65
Max. Negotiated Rate	$319.00
Rate for Payer: Buckeye Medicare Advantage	$319.00
Rate for Payer: Cash Price	$159.50
Rate for Payer: Multiplan PHCS	$191.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$223.30
Rate for Payer: UHCCP Medicaid	$111.65

SRA/IPL LMTD FACLSR-PP#2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200453
Hospital Revenue Code	222
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$159.00
Rate for Payer: Buckeye Medicare Advantage	$159.00
Rate for Payer: Cash Price	$79.50
Rate for Payer: Multiplan PHCS	$95.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$111.30
Rate for Payer: UHCCP Medicaid	$55.65

SRA/IPL SPOT LASER TX

Professional

Both

$150.00

Hospital Charge Code	22200172
Hospital Revenue Code	222
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$150.00
Rate for Payer: Buckeye Medicare Advantage	$150.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Multiplan PHCS	$90.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$105.00
Rate for Payer: UHCCP Medicaid	$52.50

SRA/IPL SPOT LSR-PP#1 50%

Professional

Both

$192.00

Hospital Charge Code	22200336
Hospital Revenue Code	222
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$192.00
Rate for Payer: Buckeye Medicare Advantage	$192.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Multiplan PHCS	$115.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$134.40
Rate for Payer: UHCCP Medicaid	$67.20

SRA/IPL SPOT LSR-PP#2/3 25%

Professional

Both

$95.00

Hospital Charge Code	22200452
Hospital Revenue Code	222
Min. Negotiated Rate	$33.25
Max. Negotiated Rate	$95.00
Rate for Payer: Buckeye Medicare Advantage	$95.00
Rate for Payer: Cash Price	$47.50
Rate for Payer: Multiplan PHCS	$57.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$66.50
Rate for Payer: UHCCP Medicaid	$33.25

SROM 11/13 40MM SPEC +0

Facility

$8,818.12

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,146.36
Max. Negotiated Rate	$8,465.40
Rate for Payer: Aetna Commercial	$6,789.95
Rate for Payer: Anthem Medicaid	$3,032.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,878.13
Rate for Payer: Cash Price	$4,409.06
Rate for Payer: Cigna Commercial	$7,319.04
Rate for Payer: First Health Commercial	$8,377.21
Rate for Payer: Humana Commercial	$7,495.40
Rate for Payer: Humana KY Medicaid	$3,032.55
Rate for Payer: Kentucky WC Medicaid	$3,063.41
Rate for Payer: Medical Mutual Of Ohio HMO	$7,230.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,507.77
Rate for Payer: Molina Healthcare Benefit Exchange	$2,645.44
Rate for Payer: Molina Healthcare Medicaid	$3,093.40
Rate for Payer: Ohio Health Choice Commercial	$7,759.95
Rate for Payer: Ohio Health Group HMO	$6,613.59
Rate for Payer: Ohio Health Group PPO Differential	$1,763.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,146.36
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,733.62
Rate for Payer: PHCS Commercial	$8,465.40
Rate for Payer: United Healthcare All Payer	$7,759.95

SROM 11/13 40MM SPEC +0

Facility

$8,818.12

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,146.36
Max. Negotiated Rate	$8,465.40
Rate for Payer: Aetna Commercial	$6,789.95
Rate for Payer: Anthem POS/PPO/Traditional	$6,878.13
Rate for Payer: Cash Price	$4,409.06
Rate for Payer: Cigna Commercial	$7,319.04
Rate for Payer: First Health Commercial	$8,377.21
Rate for Payer: Humana Commercial	$7,495.40
Rate for Payer: Medical Mutual Of Ohio HMO	$7,230.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,507.77
Rate for Payer: Molina Healthcare Benefit Exchange	$2,645.44
Rate for Payer: Ohio Health Choice Commercial	$7,759.95
Rate for Payer: Ohio Health Group HMO	$6,613.59
Rate for Payer: Ohio Health Group PPO Differential	$1,763.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,146.36
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,733.62
Rate for Payer: PHCS Commercial	$8,465.40
Rate for Payer: United Healthcare All Payer	$7,759.95

SROM 11/13 40MM SPEC +3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 40MM SPEC +3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 40MM SPEC -3

Facility

$7,902.70

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,027.35
Max. Negotiated Rate	$7,586.59
Rate for Payer: Aetna Commercial	$6,085.08
Rate for Payer: Anthem Medicaid	$2,717.74
Rate for Payer: Anthem POS/PPO/Traditional	$6,164.11
Rate for Payer: Cash Price	$3,951.35
Rate for Payer: Cigna Commercial	$6,559.24
Rate for Payer: First Health Commercial	$7,507.56
Rate for Payer: Humana Commercial	$6,717.30
Rate for Payer: Humana KY Medicaid	$2,717.74
Rate for Payer: Kentucky WC Medicaid	$2,745.40
Rate for Payer: Medical Mutual Of Ohio HMO	$6,480.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,832.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,370.81
Rate for Payer: Molina Healthcare Medicaid	$2,772.27
Rate for Payer: Ohio Health Choice Commercial	$6,954.38
Rate for Payer: Ohio Health Group HMO	$5,927.02
Rate for Payer: Ohio Health Group PPO Differential	$1,580.54
Rate for Payer: Ohio Health Group PPO No Differential	$1,027.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,449.84
Rate for Payer: PHCS Commercial	$7,586.59
Rate for Payer: United Healthcare All Payer	$6,954.38

SROM 11/13 40MM SPEC -3

Facility

$7,902.70

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,027.35
Max. Negotiated Rate	$7,586.59
Rate for Payer: Aetna Commercial	$6,085.08
Rate for Payer: Anthem POS/PPO/Traditional	$6,164.11
Rate for Payer: Cash Price	$3,951.35
Rate for Payer: Cigna Commercial	$6,559.24
Rate for Payer: First Health Commercial	$7,507.56
Rate for Payer: Humana Commercial	$6,717.30
Rate for Payer: Medical Mutual Of Ohio HMO	$6,480.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,832.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,370.81
Rate for Payer: Ohio Health Choice Commercial	$6,954.38
Rate for Payer: Ohio Health Group HMO	$5,927.02
Rate for Payer: Ohio Health Group PPO Differential	$1,580.54
Rate for Payer: Ohio Health Group PPO No Differential	$1,027.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,449.84
Rate for Payer: PHCS Commercial	$7,586.59
Rate for Payer: United Healthcare All Payer	$6,954.38

SROM 11/13 40MM SPEC +6

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 40MM SPEC +6

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +0

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +0

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +12

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +12

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC -3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC -3

Facility

$9,050.26

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.53
Max. Negotiated Rate	$8,688.25
Rate for Payer: Aetna Commercial	$6,968.70
Rate for Payer: Anthem Medicaid	$3,112.38
Rate for Payer: Anthem POS/PPO/Traditional	$7,059.20
Rate for Payer: Cash Price	$4,525.13
Rate for Payer: Cigna Commercial	$7,511.72
Rate for Payer: First Health Commercial	$8,597.75
Rate for Payer: Humana Commercial	$7,692.72
Rate for Payer: Humana KY Medicaid	$3,112.38
Rate for Payer: Kentucky WC Medicaid	$3,144.06
Rate for Payer: Medical Mutual Of Ohio HMO	$7,421.21
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,679.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,715.08
Rate for Payer: Molina Healthcare Medicaid	$3,174.83
Rate for Payer: Ohio Health Choice Commercial	$7,964.23
Rate for Payer: Ohio Health Group HMO	$6,787.70
Rate for Payer: Ohio Health Group PPO Differential	$1,810.05
Rate for Payer: Ohio Health Group PPO No Differential	$1,176.53
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,805.58
Rate for Payer: PHCS Commercial	$8,688.25
Rate for Payer: United Healthcare All Payer	$7,964.23

SROM 11/13 44MM SPEC +6

Facility

$12,133.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,577.29
Max. Negotiated Rate	$11,647.68
Rate for Payer: Aetna Commercial	$9,342.41
Rate for Payer: Anthem Medicaid	$4,172.54
Rate for Payer: Anthem POS/PPO/Traditional	$9,463.74
Rate for Payer: Cash Price	$6,066.50
Rate for Payer: Cigna Commercial	$10,070.39
Rate for Payer: First Health Commercial	$11,526.35
Rate for Payer: Humana Commercial	$10,313.05
Rate for Payer: Humana KY Medicaid	$4,172.54
Rate for Payer: Kentucky WC Medicaid	$4,215.00
Rate for Payer: Medical Mutual Of Ohio HMO	$9,949.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,954.15
Rate for Payer: Molina Healthcare Benefit Exchange	$3,639.90
Rate for Payer: Molina Healthcare Medicaid	$4,256.26
Rate for Payer: Ohio Health Choice Commercial	$10,677.04
Rate for Payer: Ohio Health Group HMO	$9,099.75
Rate for Payer: Ohio Health Group PPO Differential	$2,426.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,577.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,761.23
Rate for Payer: PHCS Commercial	$11,647.68
Rate for Payer: United Healthcare All Payer	$10,677.04

SROM 11/13 44MM SPEC +6

Facility

$12,133.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,577.29
Max. Negotiated Rate	$11,647.68
Rate for Payer: Aetna Commercial	$9,342.41
Rate for Payer: Anthem POS/PPO/Traditional	$9,463.74
Rate for Payer: Cash Price	$6,066.50
Rate for Payer: Cigna Commercial	$10,070.39
Rate for Payer: First Health Commercial	$11,526.35
Rate for Payer: Humana Commercial	$10,313.05
Rate for Payer: Medical Mutual Of Ohio HMO	$9,949.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,954.15
Rate for Payer: Molina Healthcare Benefit Exchange	$3,639.90
Rate for Payer: Ohio Health Choice Commercial	$10,677.04
Rate for Payer: Ohio Health Group HMO	$9,099.75
Rate for Payer: Ohio Health Group PPO Differential	$2,426.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,577.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,761.23
Rate for Payer: PHCS Commercial	$11,647.68
Rate for Payer: United Healthcare All Payer	$10,677.04

SROM 11/13 44MM SPEC +9

Facility

$12,133.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,577.29
Max. Negotiated Rate	$11,647.68
Rate for Payer: Aetna Commercial	$9,342.41
Rate for Payer: Anthem Medicaid	$4,172.54
Rate for Payer: Anthem POS/PPO/Traditional	$9,463.74
Rate for Payer: Cash Price	$6,066.50
Rate for Payer: Cigna Commercial	$10,070.39
Rate for Payer: First Health Commercial	$11,526.35
Rate for Payer: Humana Commercial	$10,313.05
Rate for Payer: Humana KY Medicaid	$4,172.54
Rate for Payer: Kentucky WC Medicaid	$4,215.00
Rate for Payer: Medical Mutual Of Ohio HMO	$9,949.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,954.15
Rate for Payer: Molina Healthcare Benefit Exchange	$3,639.90
Rate for Payer: Molina Healthcare Medicaid	$4,256.26
Rate for Payer: Ohio Health Choice Commercial	$10,677.04
Rate for Payer: Ohio Health Group HMO	$9,099.75
Rate for Payer: Ohio Health Group PPO Differential	$2,426.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,577.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,761.23
Rate for Payer: PHCS Commercial	$11,647.68
Rate for Payer: United Healthcare All Payer	$10,677.04

SROM 11/13 44MM SPEC +9

Facility

$12,133.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,577.29
Max. Negotiated Rate	$11,647.68
Rate for Payer: Aetna Commercial	$9,342.41
Rate for Payer: Anthem POS/PPO/Traditional	$9,463.74
Rate for Payer: Cash Price	$6,066.50
Rate for Payer: Cigna Commercial	$10,070.39
Rate for Payer: First Health Commercial	$11,526.35
Rate for Payer: Humana Commercial	$10,313.05
Rate for Payer: Medical Mutual Of Ohio HMO	$9,949.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,954.15
Rate for Payer: Molina Healthcare Benefit Exchange	$3,639.90
Rate for Payer: Ohio Health Choice Commercial	$10,677.04
Rate for Payer: Ohio Health Group HMO	$9,099.75
Rate for Payer: Ohio Health Group PPO Differential	$2,426.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,577.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,761.23
Rate for Payer: PHCS Commercial	$11,647.68
Rate for Payer: United Healthcare All Payer	$10,677.04

Know your out-of-pocket cost for care.

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