Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

STENT SENTINOLBIL 5*60*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 5*60*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 5*80*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 5*80*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 6*20*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 6*20*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 6*40*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 6*40*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 6*59*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 6*59*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 6*79*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 6*79*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 7*20*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 7*20*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 7*41*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 7*41*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 7*59*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 7*59*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 7*78*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem Medicaid	$2,594.73
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Humana KY Medicaid	$2,594.73
Rate for Payer: Kentucky WC Medicaid	$2,621.13
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Molina Healthcare Medicaid	$2,646.79
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 7*78*135

Facility

$7,545.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$980.85
Max. Negotiated Rate	$7,243.20
Rate for Payer: Aetna Commercial	$5,809.65
Rate for Payer: Anthem POS/PPO/Traditional	$5,885.10
Rate for Payer: Cash Price	$3,772.50
Rate for Payer: Cigna Commercial	$6,262.35
Rate for Payer: First Health Commercial	$7,167.75
Rate for Payer: Humana Commercial	$6,413.25
Rate for Payer: Medical Mutual Of Ohio HMO	$6,186.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,568.21
Rate for Payer: Molina Healthcare Benefit Exchange	$2,263.50
Rate for Payer: Ohio Health Choice Commercial	$6,639.60
Rate for Payer: Ohio Health Group HMO	$5,658.75
Rate for Payer: Ohio Health Group PPO Differential	$1,509.00
Rate for Payer: Ohio Health Group PPO No Differential	$980.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,338.95
Rate for Payer: PHCS Commercial	$7,243.20
Rate for Payer: United Healthcare All Payer	$6,639.60

STENT SENTINOLBIL 8*21*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 8*21*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 8*40*75

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 8*40*75

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

STENT SENTINOLBIL 8*42*135

Facility

$7,180.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$933.40
Max. Negotiated Rate	$6,892.80
Rate for Payer: Aetna Commercial	$5,528.60
Rate for Payer: Anthem Medicaid	$2,469.20
Rate for Payer: Anthem POS/PPO/Traditional	$5,600.40
Rate for Payer: Cash Price	$3,590.00
Rate for Payer: Cigna Commercial	$5,959.40
Rate for Payer: First Health Commercial	$6,821.00
Rate for Payer: Humana Commercial	$6,103.00
Rate for Payer: Humana KY Medicaid	$2,469.20
Rate for Payer: Kentucky WC Medicaid	$2,494.33
Rate for Payer: Medical Mutual Of Ohio HMO	$5,887.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,298.84
Rate for Payer: Molina Healthcare Benefit Exchange	$2,154.00
Rate for Payer: Molina Healthcare Medicaid	$2,518.74
Rate for Payer: Ohio Health Choice Commercial	$6,318.40
Rate for Payer: Ohio Health Group HMO	$5,385.00
Rate for Payer: Ohio Health Group PPO Differential	$1,436.00
Rate for Payer: Ohio Health Group PPO No Differential	$933.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,225.80
Rate for Payer: PHCS Commercial	$6,892.80
Rate for Payer: United Healthcare All Payer	$6,318.40

Know your out-of-pocket cost for care.

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