Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

STEM STD TI/HA NON-CEM 9

Facility

$11,330.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.90
Max. Negotiated Rate	$10,876.80
Rate for Payer: Aetna Commercial	$8,724.10
Rate for Payer: Anthem Medicaid	$3,896.39
Rate for Payer: Anthem POS/PPO/Traditional	$8,837.40
Rate for Payer: Cash Price	$5,665.00
Rate for Payer: Cigna Commercial	$9,403.90
Rate for Payer: First Health Commercial	$10,763.50
Rate for Payer: Humana Commercial	$9,630.50
Rate for Payer: Humana KY Medicaid	$3,896.39
Rate for Payer: Kentucky WC Medicaid	$3,936.04
Rate for Payer: Medical Mutual Of Ohio HMO	$9,290.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,361.54
Rate for Payer: Molina Healthcare Benefit Exchange	$3,399.00
Rate for Payer: Molina Healthcare Medicaid	$3,974.56
Rate for Payer: Ohio Health Choice Commercial	$9,970.40
Rate for Payer: Ohio Health Group HMO	$8,497.50
Rate for Payer: Ohio Health Group PPO Differential	$2,266.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,472.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,512.30
Rate for Payer: PHCS Commercial	$10,876.80
Rate for Payer: United Healthcare All Payer	$9,970.40

STEM STD TI/HA NON-CEM 9

Facility

$11,330.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.90
Max. Negotiated Rate	$10,876.80
Rate for Payer: Aetna Commercial	$8,724.10
Rate for Payer: Anthem POS/PPO/Traditional	$8,837.40
Rate for Payer: Cash Price	$5,665.00
Rate for Payer: Cigna Commercial	$9,403.90
Rate for Payer: First Health Commercial	$10,763.50
Rate for Payer: Humana Commercial	$9,630.50
Rate for Payer: Medical Mutual Of Ohio HMO	$9,290.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,361.54
Rate for Payer: Molina Healthcare Benefit Exchange	$3,399.00
Rate for Payer: Ohio Health Choice Commercial	$9,970.40
Rate for Payer: Ohio Health Group HMO	$8,497.50
Rate for Payer: Ohio Health Group PPO Differential	$2,266.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,472.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,512.30
Rate for Payer: PHCS Commercial	$10,876.80
Rate for Payer: United Healthcare All Payer	$9,970.40

STEM STRAIGHT OSS 11X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRAIGHT OSS 11X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem Medicaid	$5,198.61
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Humana KY Medicaid	$5,198.61
Rate for Payer: Kentucky WC Medicaid	$5,251.52
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Molina Healthcare Medicaid	$5,302.92
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRAIGHT OSS 13X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem Medicaid	$5,198.61
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Humana KY Medicaid	$5,198.61
Rate for Payer: Kentucky WC Medicaid	$5,251.52
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Molina Healthcare Medicaid	$5,302.92
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRAIGHT OSS 13X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRAIGHT OSS 15X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRAIGHT OSS 15X225

Facility

$15,116.64

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,965.16
Max. Negotiated Rate	$14,511.97
Rate for Payer: Aetna Commercial	$11,639.81
Rate for Payer: Anthem Medicaid	$5,198.61
Rate for Payer: Anthem POS/PPO/Traditional	$11,790.98
Rate for Payer: Cash Price	$7,558.32
Rate for Payer: Cigna Commercial	$12,546.81
Rate for Payer: First Health Commercial	$14,360.81
Rate for Payer: Humana Commercial	$12,849.14
Rate for Payer: Humana KY Medicaid	$5,198.61
Rate for Payer: Kentucky WC Medicaid	$5,251.52
Rate for Payer: Medical Mutual Of Ohio HMO	$12,395.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,156.08
Rate for Payer: Molina Healthcare Benefit Exchange	$4,534.99
Rate for Payer: Molina Healthcare Medicaid	$5,302.92
Rate for Payer: Ohio Health Choice Commercial	$13,302.64
Rate for Payer: Ohio Health Group HMO	$11,337.48
Rate for Payer: Ohio Health Group PPO Differential	$3,023.33
Rate for Payer: Ohio Health Group PPO No Differential	$1,965.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,686.16
Rate for Payer: PHCS Commercial	$14,511.97
Rate for Payer: United Healthcare All Payer	$13,302.64

STEM STRGHT CLRED OSS 11X150

Facility

$13,417.80

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,744.31
Max. Negotiated Rate	$12,881.09
Rate for Payer: Aetna Commercial	$10,331.71
Rate for Payer: Anthem Medicaid	$4,614.38
Rate for Payer: Anthem POS/PPO/Traditional	$10,465.88
Rate for Payer: Cash Price	$6,708.90
Rate for Payer: Cigna Commercial	$11,136.77
Rate for Payer: First Health Commercial	$12,746.91
Rate for Payer: Humana Commercial	$11,405.13
Rate for Payer: Humana KY Medicaid	$4,614.38
Rate for Payer: Kentucky WC Medicaid	$4,661.34
Rate for Payer: Medical Mutual Of Ohio HMO	$11,002.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,902.34
Rate for Payer: Molina Healthcare Benefit Exchange	$4,025.34
Rate for Payer: Molina Healthcare Medicaid	$4,706.96
Rate for Payer: Ohio Health Choice Commercial	$11,807.66
Rate for Payer: Ohio Health Group HMO	$10,063.35
Rate for Payer: Ohio Health Group PPO Differential	$2,683.56
Rate for Payer: Ohio Health Group PPO No Differential	$1,744.31
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,159.52
Rate for Payer: PHCS Commercial	$12,881.09
Rate for Payer: United Healthcare All Payer	$11,807.66

STEM STRGHT CLRED OSS 11X150

Facility

$13,417.80

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,744.31
Max. Negotiated Rate	$12,881.09
Rate for Payer: Aetna Commercial	$10,331.71
Rate for Payer: Anthem POS/PPO/Traditional	$10,465.88
Rate for Payer: Cash Price	$6,708.90
Rate for Payer: Cigna Commercial	$11,136.77
Rate for Payer: First Health Commercial	$12,746.91
Rate for Payer: Humana Commercial	$11,405.13
Rate for Payer: Medical Mutual Of Ohio HMO	$11,002.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,902.34
Rate for Payer: Molina Healthcare Benefit Exchange	$4,025.34
Rate for Payer: Ohio Health Choice Commercial	$11,807.66
Rate for Payer: Ohio Health Group HMO	$10,063.35
Rate for Payer: Ohio Health Group PPO Differential	$2,683.56
Rate for Payer: Ohio Health Group PPO No Differential	$1,744.31
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,159.52
Rate for Payer: PHCS Commercial	$12,881.09
Rate for Payer: United Healthcare All Payer	$11,807.66

STEM STRGHT COLLARED OSS 9X150

Facility

$13,417.80

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,744.31
Max. Negotiated Rate	$12,881.09
Rate for Payer: Aetna Commercial	$10,331.71
Rate for Payer: Anthem POS/PPO/Traditional	$10,465.88
Rate for Payer: Cash Price	$6,708.90
Rate for Payer: Cigna Commercial	$11,136.77
Rate for Payer: First Health Commercial	$12,746.91
Rate for Payer: Humana Commercial	$11,405.13
Rate for Payer: Medical Mutual Of Ohio HMO	$11,002.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,902.34
Rate for Payer: Molina Healthcare Benefit Exchange	$4,025.34
Rate for Payer: Ohio Health Choice Commercial	$11,807.66
Rate for Payer: Ohio Health Group HMO	$10,063.35
Rate for Payer: Ohio Health Group PPO Differential	$2,683.56
Rate for Payer: Ohio Health Group PPO No Differential	$1,744.31
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,159.52
Rate for Payer: PHCS Commercial	$12,881.09
Rate for Payer: United Healthcare All Payer	$11,807.66

STEM STRGHT COLLARED OSS 9X150

Facility

$13,417.80

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,744.31
Max. Negotiated Rate	$12,881.09
Rate for Payer: Aetna Commercial	$10,331.71
Rate for Payer: Anthem Medicaid	$4,614.38
Rate for Payer: Anthem POS/PPO/Traditional	$10,465.88
Rate for Payer: Cash Price	$6,708.90
Rate for Payer: Cigna Commercial	$11,136.77
Rate for Payer: First Health Commercial	$12,746.91
Rate for Payer: Humana Commercial	$11,405.13
Rate for Payer: Humana KY Medicaid	$4,614.38
Rate for Payer: Kentucky WC Medicaid	$4,661.34
Rate for Payer: Medical Mutual Of Ohio HMO	$11,002.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,902.34
Rate for Payer: Molina Healthcare Benefit Exchange	$4,025.34
Rate for Payer: Molina Healthcare Medicaid	$4,706.96
Rate for Payer: Ohio Health Choice Commercial	$11,807.66
Rate for Payer: Ohio Health Group HMO	$10,063.35
Rate for Payer: Ohio Health Group PPO Differential	$2,683.56
Rate for Payer: Ohio Health Group PPO No Differential	$1,744.31
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,159.52
Rate for Payer: PHCS Commercial	$12,881.09
Rate for Payer: United Healthcare All Payer	$11,807.66

STEM STRT GRIT BLST PS 10X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 10X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 11X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 11X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 12X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 12X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 13X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 13X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 14X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 14X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 15X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 15X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

STEM STRT GRIT BLST PS 16X220

Facility

$12,873.04

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,673.50
Max. Negotiated Rate	$12,358.12
Rate for Payer: Aetna Commercial	$9,912.24
Rate for Payer: Anthem Medicaid	$4,427.04
Rate for Payer: Anthem POS/PPO/Traditional	$10,040.97
Rate for Payer: Cash Price	$6,436.52
Rate for Payer: Cigna Commercial	$10,684.62
Rate for Payer: First Health Commercial	$12,229.39
Rate for Payer: Humana Commercial	$10,942.08
Rate for Payer: Humana KY Medicaid	$4,427.04
Rate for Payer: Kentucky WC Medicaid	$4,472.09
Rate for Payer: Medical Mutual Of Ohio HMO	$10,555.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,500.30
Rate for Payer: Molina Healthcare Benefit Exchange	$3,861.91
Rate for Payer: Molina Healthcare Medicaid	$4,515.86
Rate for Payer: Ohio Health Choice Commercial	$11,328.28
Rate for Payer: Ohio Health Group HMO	$9,654.78
Rate for Payer: Ohio Health Group PPO Differential	$2,574.61
Rate for Payer: Ohio Health Group PPO No Differential	$1,673.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,990.64
Rate for Payer: PHCS Commercial	$12,358.12
Rate for Payer: United Healthcare All Payer	$11,328.28

Know your out-of-pocket cost for care.

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