Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$8,709.32

Service Code	MSDRG 122
Min. Negotiated Rate	$5,909.89
Max. Negotiated Rate	$8,709.32
Rate for Payer: Anthem Medicaid	$5,909.89
Rate for Payer: Anthem Medicare Advantage/PPO	$6,220.94
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,709.32
Rate for Payer: CareSource Just4Me Medicare	$8,398.27
Rate for Payer: Humana KY Medicaid	$5,909.89
Rate for Payer: Humana Medicare Advantage	$6,220.94
Rate for Payer: Kentucky WC Medicaid	$5,968.99
Rate for Payer: Molina Healthcare Benefit Exchange	$7,465.13
Rate for Payer: Molina Healthcare Medicaid	$6,028.09

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$10,680.45

Service Code	MSDRG 281
Min. Negotiated Rate	$7,247.45
Max. Negotiated Rate	$10,680.45
Rate for Payer: Anthem Medicaid	$7,247.45
Rate for Payer: Anthem Medicare Advantage/PPO	$7,628.89
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$10,680.45
Rate for Payer: CareSource Just4Me Medicare	$10,299.00
Rate for Payer: Humana KY Medicaid	$7,247.45
Rate for Payer: Humana Medicare Advantage	$7,628.89
Rate for Payer: Kentucky WC Medicaid	$7,319.92
Rate for Payer: Molina Healthcare Benefit Exchange	$9,154.67
Rate for Payer: Molina Healthcare Medicaid	$7,392.39

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$18,559.24

Service Code	MSDRG 280
Min. Negotiated Rate	$12,593.77
Max. Negotiated Rate	$18,559.24
Rate for Payer: Anthem Medicaid	$12,593.77
Rate for Payer: Anthem Medicare Advantage/PPO	$13,256.60
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$18,559.24
Rate for Payer: CareSource Just4Me Medicare	$17,896.41
Rate for Payer: Humana KY Medicaid	$12,593.77
Rate for Payer: Humana Medicare Advantage	$13,256.60
Rate for Payer: Kentucky WC Medicaid	$12,719.71
Rate for Payer: Molina Healthcare Benefit Exchange	$15,907.92
Rate for Payer: Molina Healthcare Medicaid	$12,845.65

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$8,400.49

Service Code	MSDRG 282
Min. Negotiated Rate	$5,700.33
Max. Negotiated Rate	$8,400.49
Rate for Payer: Anthem Medicaid	$5,700.33
Rate for Payer: Anthem Medicare Advantage/PPO	$6,000.35
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,400.49
Rate for Payer: CareSource Just4Me Medicare	$8,100.47
Rate for Payer: Humana KY Medicaid	$5,700.33
Rate for Payer: Humana Medicare Advantage	$6,000.35
Rate for Payer: Kentucky WC Medicaid	$5,757.34
Rate for Payer: Molina Healthcare Benefit Exchange	$7,200.42
Rate for Payer: Molina Healthcare Medicaid	$5,814.34

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$8,653.18

Service Code	MSDRG 284
Min. Negotiated Rate	$5,871.80
Max. Negotiated Rate	$8,653.18
Rate for Payer: Anthem Medicaid	$5,871.80
Rate for Payer: Anthem Medicare Advantage/PPO	$6,180.84
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,653.18
Rate for Payer: CareSource Just4Me Medicare	$8,344.13
Rate for Payer: Humana KY Medicaid	$5,871.80
Rate for Payer: Humana Medicare Advantage	$6,180.84
Rate for Payer: Kentucky WC Medicaid	$5,930.52
Rate for Payer: Molina Healthcare Benefit Exchange	$7,417.01
Rate for Payer: Molina Healthcare Medicaid	$5,989.23

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$23,061.84

Service Code	MSDRG 283
Min. Negotiated Rate	$15,649.10
Max. Negotiated Rate	$23,061.84
Rate for Payer: Anthem Medicaid	$15,649.10
Rate for Payer: Anthem Medicare Advantage/PPO	$16,472.74
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,061.84
Rate for Payer: CareSource Just4Me Medicare	$22,238.20
Rate for Payer: Humana KY Medicaid	$15,649.10
Rate for Payer: Humana Medicare Advantage	$16,472.74
Rate for Payer: Kentucky WC Medicaid	$15,805.59
Rate for Payer: Molina Healthcare Benefit Exchange	$19,767.29
Rate for Payer: Molina Healthcare Medicaid	$15,962.09

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$5,716.91

Service Code	MSDRG 285
Min. Negotiated Rate	$3,879.33
Max. Negotiated Rate	$5,716.91
Rate for Payer: Anthem Medicaid	$3,879.33
Rate for Payer: Anthem Medicare Advantage/PPO	$4,083.51
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$5,716.91
Rate for Payer: CareSource Just4Me Medicare	$5,512.74
Rate for Payer: Humana KY Medicaid	$3,879.33
Rate for Payer: Humana Medicare Advantage	$4,083.51
Rate for Payer: Kentucky WC Medicaid	$3,918.13
Rate for Payer: Molina Healthcare Benefit Exchange	$4,900.21
Rate for Payer: Molina Healthcare Medicaid	$3,956.92

ACUTE OBS ADM/DC SAMEDAY LVL 1

Facility

$1,679.00

Service Code	HCPCS 99234
Hospital Charge Code	76200021
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS ADM/DC SAMEDAY LVL 1

Facility

$1,679.00

Service Code	HCPCS 99234
Hospital Charge Code	76200021
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem Medicaid	$577.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Humana KY Medicaid	$577.41
Rate for Payer: Kentucky WC Medicaid	$583.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Molina Healthcare Medicaid	$588.99
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS ADM/DC SAMEDAY LVL 2

Facility

$1,679.00

Service Code	HCPCS 99235
Hospital Charge Code	76200022
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS ADM/DC SAMEDAY LVL 2

Facility

$1,679.00

Service Code	HCPCS 99235
Hospital Charge Code	76200022
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem Medicaid	$577.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Humana KY Medicaid	$577.41
Rate for Payer: Kentucky WC Medicaid	$583.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Molina Healthcare Medicaid	$588.99
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS ADM/DC SAMEDAY LVL 3

Facility

$1,679.00

Service Code	HCPCS 99236
Hospital Charge Code	76200023
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS ADM/DC SAMEDAY LVL 3

Facility

$1,679.00

Service Code	HCPCS 99236
Hospital Charge Code	76200023
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem Medicaid	$577.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Humana KY Medicaid	$577.41
Rate for Payer: Kentucky WC Medicaid	$583.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Molina Healthcare Medicaid	$588.99
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS CARE <30M

Facility

$1,679.00

Service Code	HCPCS 99238
Hospital Charge Code	76200014
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem Medicaid	$577.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Humana KY Medicaid	$577.41
Rate for Payer: Kentucky WC Medicaid	$583.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Molina Healthcare Medicaid	$588.99
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE OBS CARE <30M

Facility

$1,679.00

Service Code	HCPCS 99238
Hospital Charge Code	76200014
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE SUBSEQ OBS PER DAY LVL 1

Facility

$1,679.00

Service Code	HCPCS 99231
Hospital Charge Code	76200018
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE SUBSEQ OBS PER DAY LVL 1

Facility

$1,679.00

Service Code	HCPCS 99231
Hospital Charge Code	76200018
Hospital Revenue Code	762
Min. Negotiated Rate	$218.27
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$1,292.83
Rate for Payer: Anthem Medicaid	$577.41
Rate for Payer: Anthem POS/PPO/Traditional	$1,309.62
Rate for Payer: Cash Price	$839.50
Rate for Payer: Cigna Commercial	$1,393.57
Rate for Payer: First Health Commercial	$1,595.05
Rate for Payer: Humana Commercial	$1,427.15
Rate for Payer: Humana KY Medicaid	$577.41
Rate for Payer: Kentucky WC Medicaid	$583.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,376.78
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,239.10
Rate for Payer: Molina Healthcare Benefit Exchange	$503.70
Rate for Payer: Molina Healthcare Medicaid	$588.99
Rate for Payer: Ohio Health Choice Commercial	$1,477.52
Rate for Payer: Ohio Health Group HMO	$1,259.25
Rate for Payer: Ohio Health Group PPO Differential	$335.80
Rate for Payer: Ohio Health Group PPO No Differential	$218.27
Rate for Payer: Ohio Health Group PPO SOMC Employees	$520.49
Rate for Payer: PHCS Commercial	$1,611.84
Rate for Payer: United Healthcare All Payer	$1,477.52

ACUTE SUBSEQ OBS PER DAY LVL 2

Facility

$3,034.00

Service Code	HCPCS 99232
Hospital Charge Code	76200019
Hospital Revenue Code	762
Min. Negotiated Rate	$394.42
Max. Negotiated Rate	$2,912.64
Rate for Payer: Aetna Commercial	$2,336.18
Rate for Payer: Anthem POS/PPO/Traditional	$2,366.52
Rate for Payer: Cash Price	$1,517.00
Rate for Payer: Cigna Commercial	$2,518.22
Rate for Payer: First Health Commercial	$2,882.30
Rate for Payer: Humana Commercial	$2,578.90
Rate for Payer: Medical Mutual Of Ohio HMO	$2,487.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,239.09
Rate for Payer: Molina Healthcare Benefit Exchange	$910.20
Rate for Payer: Ohio Health Choice Commercial	$2,669.92
Rate for Payer: Ohio Health Group HMO	$2,275.50
Rate for Payer: Ohio Health Group PPO Differential	$606.80
Rate for Payer: Ohio Health Group PPO No Differential	$394.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$940.54
Rate for Payer: PHCS Commercial	$2,912.64
Rate for Payer: United Healthcare All Payer	$2,669.92

ACUTE SUBSEQ OBS PER DAY LVL 2

Facility

$3,034.00

Service Code	HCPCS 99232
Hospital Charge Code	76200019
Hospital Revenue Code	762
Min. Negotiated Rate	$394.42
Max. Negotiated Rate	$2,912.64
Rate for Payer: Aetna Commercial	$2,336.18
Rate for Payer: Anthem Medicaid	$1,043.39
Rate for Payer: Anthem POS/PPO/Traditional	$2,366.52
Rate for Payer: Cash Price	$1,517.00
Rate for Payer: Cigna Commercial	$2,518.22
Rate for Payer: First Health Commercial	$2,882.30
Rate for Payer: Humana Commercial	$2,578.90
Rate for Payer: Humana KY Medicaid	$1,043.39
Rate for Payer: Kentucky WC Medicaid	$1,054.01
Rate for Payer: Medical Mutual Of Ohio HMO	$2,487.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,239.09
Rate for Payer: Molina Healthcare Benefit Exchange	$910.20
Rate for Payer: Molina Healthcare Medicaid	$1,064.33
Rate for Payer: Ohio Health Choice Commercial	$2,669.92
Rate for Payer: Ohio Health Group HMO	$2,275.50
Rate for Payer: Ohio Health Group PPO Differential	$606.80
Rate for Payer: Ohio Health Group PPO No Differential	$394.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$940.54
Rate for Payer: PHCS Commercial	$2,912.64
Rate for Payer: United Healthcare All Payer	$2,669.92

ACUTE SUBSEQ OBS PER DAY LVL 3

Facility

$3,432.00

Service Code	HCPCS 99233
Hospital Charge Code	76200020
Hospital Revenue Code	762
Min. Negotiated Rate	$446.16
Max. Negotiated Rate	$3,294.72
Rate for Payer: Aetna Commercial	$2,642.64
Rate for Payer: Anthem Medicaid	$1,180.26
Rate for Payer: Anthem POS/PPO/Traditional	$2,676.96
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Cigna Commercial	$2,848.56
Rate for Payer: First Health Commercial	$3,260.40
Rate for Payer: Humana Commercial	$2,917.20
Rate for Payer: Humana KY Medicaid	$1,180.26
Rate for Payer: Kentucky WC Medicaid	$1,192.28
Rate for Payer: Medical Mutual Of Ohio HMO	$2,814.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,532.82
Rate for Payer: Molina Healthcare Benefit Exchange	$1,029.60
Rate for Payer: Molina Healthcare Medicaid	$1,203.95
Rate for Payer: Ohio Health Choice Commercial	$3,020.16
Rate for Payer: Ohio Health Group HMO	$2,574.00
Rate for Payer: Ohio Health Group PPO Differential	$686.40
Rate for Payer: Ohio Health Group PPO No Differential	$446.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,063.92
Rate for Payer: PHCS Commercial	$3,294.72
Rate for Payer: United Healthcare All Payer	$3,020.16

ACUTE SUBSEQ OBS PER DAY LVL 3

Facility

$3,432.00

Service Code	HCPCS 99233
Hospital Charge Code	76200020
Hospital Revenue Code	762
Min. Negotiated Rate	$446.16
Max. Negotiated Rate	$3,294.72
Rate for Payer: Aetna Commercial	$2,642.64
Rate for Payer: Anthem POS/PPO/Traditional	$2,676.96
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Cigna Commercial	$2,848.56
Rate for Payer: First Health Commercial	$3,260.40
Rate for Payer: Humana Commercial	$2,917.20
Rate for Payer: Medical Mutual Of Ohio HMO	$2,814.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,532.82
Rate for Payer: Molina Healthcare Benefit Exchange	$1,029.60
Rate for Payer: Ohio Health Choice Commercial	$3,020.16
Rate for Payer: Ohio Health Group HMO	$2,574.00
Rate for Payer: Ohio Health Group PPO Differential	$686.40
Rate for Payer: Ohio Health Group PPO No Differential	$446.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,063.92
Rate for Payer: PHCS Commercial	$3,294.72
Rate for Payer: United Healthcare All Payer	$3,020.16

ACUTRAK 2 GUIDEWIRE 9.25*.094

Facility

$449.50

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$58.44
Max. Negotiated Rate	$431.52
Rate for Payer: Aetna Commercial	$346.12
Rate for Payer: Anthem POS/PPO/Traditional	$350.61
Rate for Payer: Cash Price	$224.75
Rate for Payer: Cigna Commercial	$373.08
Rate for Payer: First Health Commercial	$427.02
Rate for Payer: Humana Commercial	$382.08
Rate for Payer: Medical Mutual Of Ohio HMO	$368.59
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$331.73
Rate for Payer: Molina Healthcare Benefit Exchange	$134.85
Rate for Payer: Ohio Health Choice Commercial	$395.56
Rate for Payer: Ohio Health Group HMO	$337.12
Rate for Payer: Ohio Health Group PPO Differential	$89.90
Rate for Payer: Ohio Health Group PPO No Differential	$58.44
Rate for Payer: Ohio Health Group PPO SOMC Employees	$139.34
Rate for Payer: PHCS Commercial	$431.52
Rate for Payer: United Healthcare All Payer	$395.56

ACUTRAK 2 GUIDEWIRE 9.25*.094

Facility

$449.50

Service Code	HCPCS C1769
Hospital Charge Code	27000056
Hospital Revenue Code	272
Min. Negotiated Rate	$58.44
Max. Negotiated Rate	$431.52
Rate for Payer: Aetna Commercial	$346.12
Rate for Payer: Anthem Medicaid	$154.58
Rate for Payer: Anthem POS/PPO/Traditional	$350.61
Rate for Payer: Cash Price	$224.75
Rate for Payer: Cigna Commercial	$373.08
Rate for Payer: First Health Commercial	$427.02
Rate for Payer: Humana Commercial	$382.08
Rate for Payer: Humana KY Medicaid	$154.58
Rate for Payer: Kentucky WC Medicaid	$156.16
Rate for Payer: Medical Mutual Of Ohio HMO	$368.59
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$331.73
Rate for Payer: Molina Healthcare Benefit Exchange	$134.85
Rate for Payer: Molina Healthcare Medicaid	$157.68
Rate for Payer: Ohio Health Choice Commercial	$395.56
Rate for Payer: Ohio Health Group HMO	$337.12
Rate for Payer: Ohio Health Group PPO Differential	$89.90
Rate for Payer: Ohio Health Group PPO No Differential	$58.44
Rate for Payer: Ohio Health Group PPO SOMC Employees	$139.34
Rate for Payer: PHCS Commercial	$431.52
Rate for Payer: United Healthcare All Payer	$395.56

ACUTRAK 4.0 CANN DRIVER TIP

Facility

$1,582.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$205.72
Max. Negotiated Rate	$1,519.20
Rate for Payer: Aetna Commercial	$1,218.52
Rate for Payer: Anthem Medicaid	$544.22
Rate for Payer: Anthem POS/PPO/Traditional	$1,234.35
Rate for Payer: Cash Price	$791.25
Rate for Payer: Cigna Commercial	$1,313.48
Rate for Payer: First Health Commercial	$1,503.38
Rate for Payer: Humana Commercial	$1,345.12
Rate for Payer: Humana KY Medicaid	$544.22
Rate for Payer: Kentucky WC Medicaid	$549.76
Rate for Payer: Medical Mutual Of Ohio HMO	$1,297.65
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,167.88
Rate for Payer: Molina Healthcare Benefit Exchange	$474.75
Rate for Payer: Molina Healthcare Medicaid	$555.14
Rate for Payer: Ohio Health Choice Commercial	$1,392.60
Rate for Payer: Ohio Health Group HMO	$1,186.88
Rate for Payer: Ohio Health Group PPO Differential	$316.50
Rate for Payer: Ohio Health Group PPO No Differential	$205.72
Rate for Payer: Ohio Health Group PPO SOMC Employees	$490.58
Rate for Payer: PHCS Commercial	$1,519.20
Rate for Payer: United Healthcare All Payer	$1,392.60

ACUTRAK 4.0 CANN DRIVER TIP

Facility

$1,582.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$205.72
Max. Negotiated Rate	$1,519.20
Rate for Payer: Aetna Commercial	$1,218.52
Rate for Payer: Anthem POS/PPO/Traditional	$1,234.35
Rate for Payer: Cash Price	$791.25
Rate for Payer: Cigna Commercial	$1,313.48
Rate for Payer: First Health Commercial	$1,503.38
Rate for Payer: Humana Commercial	$1,345.12
Rate for Payer: Medical Mutual Of Ohio HMO	$1,297.65
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,167.88
Rate for Payer: Molina Healthcare Benefit Exchange	$474.75
Rate for Payer: Ohio Health Choice Commercial	$1,392.60
Rate for Payer: Ohio Health Group HMO	$1,186.88
Rate for Payer: Ohio Health Group PPO Differential	$316.50
Rate for Payer: Ohio Health Group PPO No Differential	$205.72
Rate for Payer: Ohio Health Group PPO SOMC Employees	$490.58
Rate for Payer: PHCS Commercial	$1,519.20
Rate for Payer: United Healthcare All Payer	$1,392.60

Know your out-of-pocket cost for care.

All Charges