Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD

Facility

$3,918.70

Service Code	CPT 28296
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD

Facility

$8,661.10

Service Code	CPT 28297
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)

Facility

$3,918.70

Service Code	CPT 28285
Hospital Revenue Code	360
Min. Negotiated Rate	$2,799.07
Max. Negotiated Rate	$3,918.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88

CORRECTION INVERTED NIPPLES

Professional

Both

$5,768.63

Service Code	HCPCS 19355
Hospital Charge Code	76100314
Hospital Revenue Code	761
Min. Negotiated Rate	$725.31
Max. Negotiated Rate	$5,768.63
Rate for Payer: Aetna Commercial	$807.74
Rate for Payer: Buckeye Medicare Advantage	$5,768.63
Rate for Payer: Cash Price	$2,884.32
Rate for Payer: Cash Price	$2,884.32
Rate for Payer: Cigna Commercial	$1,028.84
Rate for Payer: Healthspan PPO	$792.22
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$725.31
Rate for Payer: Multiplan PHCS	$3,461.18
Rate for Payer: Ohio Health Choice Preferred Health Choice	$4,038.04
Rate for Payer: UHCCP Medicaid	$2,019.02

CORRECTION INVERTED NIPPLES

Facility

$5,768.63

Service Code	HCPCS 19355
Hospital Charge Code	76100314
Hospital Revenue Code	761
Min. Negotiated Rate	$749.92
Max. Negotiated Rate	$5,537.88
Rate for Payer: Aetna Commercial	$4,441.85
Rate for Payer: Anthem Medicaid	$1,983.83
Rate for Payer: Anthem Medicare Advantage/PPO	$3,296.21
Rate for Payer: Anthem POS/PPO/Traditional	$4,499.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,614.69
Rate for Payer: CareSource Just4Me Medicare	$4,449.88
Rate for Payer: Cash Price	$2,884.32
Rate for Payer: Cash Price	$2,884.32
Rate for Payer: Cigna Commercial	$4,787.96
Rate for Payer: First Health Commercial	$5,480.20
Rate for Payer: Humana Commercial	$4,903.34
Rate for Payer: Humana KY Medicaid	$1,983.83
Rate for Payer: Humana Medicare Advantage	$3,296.21
Rate for Payer: Kentucky WC Medicaid	$2,004.02
Rate for Payer: Medical Mutual Of Ohio HMO	$4,730.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,257.25
Rate for Payer: Molina Healthcare Benefit Exchange	$3,955.45
Rate for Payer: Molina Healthcare Medicaid	$2,023.64
Rate for Payer: Ohio Health Choice Commercial	$5,076.39
Rate for Payer: Ohio Health Group HMO	$4,326.47
Rate for Payer: Ohio Health Group PPO Differential	$1,153.73
Rate for Payer: Ohio Health Group PPO No Differential	$749.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,788.28
Rate for Payer: PHCS Commercial	$5,537.88
Rate for Payer: United Healthcare All Payer	$5,076.39

CORRECTION INVERTED NIPPLES

Facility

$5,768.63

Service Code	HCPCS 19355
Hospital Charge Code	76100314
Hospital Revenue Code	761
Min. Negotiated Rate	$749.92
Max. Negotiated Rate	$5,537.88
Rate for Payer: Aetna Commercial	$4,441.85
Rate for Payer: Anthem POS/PPO/Traditional	$4,499.53
Rate for Payer: Cash Price	$2,884.32
Rate for Payer: Cigna Commercial	$4,787.96
Rate for Payer: First Health Commercial	$5,480.20
Rate for Payer: Humana Commercial	$4,903.34
Rate for Payer: Medical Mutual Of Ohio HMO	$4,730.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,257.25
Rate for Payer: Molina Healthcare Benefit Exchange	$1,730.59
Rate for Payer: Ohio Health Choice Commercial	$5,076.39
Rate for Payer: Ohio Health Group HMO	$4,326.47
Rate for Payer: Ohio Health Group PPO Differential	$1,153.73
Rate for Payer: Ohio Health Group PPO No Differential	$749.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,788.28
Rate for Payer: PHCS Commercial	$5,537.88
Rate for Payer: United Healthcare All Payer	$5,076.39

CORRECTION INVERTED NIPPLES(P

Professional

Both

$1,200.00

Service Code	HCPCS 19355
Hospital Charge Code	761P0314
Hospital Revenue Code	761
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$807.74
Rate for Payer: Buckeye Medicare Advantage	$1,200.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cigna Commercial	$1,028.84
Rate for Payer: Healthspan PPO	$792.22
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$725.31
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$840.00
Rate for Payer: UHCCP Medicaid	$420.00

CORRECTION INVERTED NIPPLES(T

Facility

$4,568.63

Service Code	HCPCS 19355
Hospital Charge Code	761T0314
Hospital Revenue Code	761
Min. Negotiated Rate	$593.92
Max. Negotiated Rate	$4,385.88
Rate for Payer: Aetna Commercial	$3,517.85
Rate for Payer: Anthem POS/PPO/Traditional	$3,563.53
Rate for Payer: Cash Price	$2,284.32
Rate for Payer: Cigna Commercial	$3,791.96
Rate for Payer: First Health Commercial	$4,340.20
Rate for Payer: Humana Commercial	$3,883.34
Rate for Payer: Medical Mutual Of Ohio HMO	$3,746.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,371.65
Rate for Payer: Molina Healthcare Benefit Exchange	$1,370.59
Rate for Payer: Ohio Health Choice Commercial	$4,020.39
Rate for Payer: Ohio Health Group HMO	$3,426.47
Rate for Payer: Ohio Health Group PPO Differential	$913.73
Rate for Payer: Ohio Health Group PPO No Differential	$593.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,416.28
Rate for Payer: PHCS Commercial	$4,385.88
Rate for Payer: United Healthcare All Payer	$4,020.39

CORRECTION INVERTED NIPPLES(T

Facility

$4,568.63

Service Code	HCPCS 19355
Hospital Charge Code	761T0314
Hospital Revenue Code	761
Min. Negotiated Rate	$593.92
Max. Negotiated Rate	$4,614.69
Rate for Payer: Aetna Commercial	$3,517.85
Rate for Payer: Anthem Medicaid	$1,571.15
Rate for Payer: Anthem Medicare Advantage/PPO	$3,296.21
Rate for Payer: Anthem POS/PPO/Traditional	$3,563.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,614.69
Rate for Payer: CareSource Just4Me Medicare	$4,449.88
Rate for Payer: Cash Price	$2,284.32
Rate for Payer: Cash Price	$2,284.32
Rate for Payer: Cigna Commercial	$3,791.96
Rate for Payer: First Health Commercial	$4,340.20
Rate for Payer: Humana Commercial	$3,883.34
Rate for Payer: Humana KY Medicaid	$1,571.15
Rate for Payer: Humana Medicare Advantage	$3,296.21
Rate for Payer: Kentucky WC Medicaid	$1,587.14
Rate for Payer: Medical Mutual Of Ohio HMO	$3,746.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,371.65
Rate for Payer: Molina Healthcare Benefit Exchange	$3,955.45
Rate for Payer: Molina Healthcare Medicaid	$1,602.68
Rate for Payer: Ohio Health Choice Commercial	$4,020.39
Rate for Payer: Ohio Health Group HMO	$3,426.47
Rate for Payer: Ohio Health Group PPO Differential	$913.73
Rate for Payer: Ohio Health Group PPO No Differential	$593.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,416.28
Rate for Payer: PHCS Commercial	$4,385.88
Rate for Payer: United Healthcare All Payer	$4,020.39

CORRECT MALROTATION OF BOWEL

Professional

Both

$2,435.00

Service Code	HCPCS 44055
Hospital Charge Code	76102660
Hospital Revenue Code	761
Min. Negotiated Rate	$594.11
Max. Negotiated Rate	$2,435.00
Rate for Payer: Aetna Commercial	$2,157.33
Rate for Payer: Anthem Medicaid	$594.11
Rate for Payer: Buckeye Medicare Advantage	$2,435.00
Rate for Payer: Cash Price	$1,217.50
Rate for Payer: Cash Price	$1,217.50
Rate for Payer: Cigna Commercial	$1,999.12
Rate for Payer: Healthspan PPO	$1,819.31
Rate for Payer: Humana Medicaid	$594.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,912.63
Rate for Payer: Molina Healthcare CHIP/Medicaid	$605.99
Rate for Payer: Molina Healthcare Passport	$594.11
Rate for Payer: Multiplan PHCS	$1,461.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,704.50
Rate for Payer: UHCCP Medicaid	$852.25
Rate for Payer: Wellcare CHIP/Medicaid	$600.05

CORRECT SKN COLOR 6.1-20.0CM

Facility

$2,572.20

Service Code	HCPCS 11921
Hospital Charge Code	76100109
Hospital Revenue Code	761
Min. Negotiated Rate	$334.39
Max. Negotiated Rate	$2,469.31
Rate for Payer: Aetna Commercial	$1,980.59
Rate for Payer: Anthem Medicaid	$884.58
Rate for Payer: Anthem Medicare Advantage/PPO	$543.11
Rate for Payer: Anthem POS/PPO/Traditional	$2,006.32
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$760.35
Rate for Payer: CareSource Just4Me Medicare	$733.20
Rate for Payer: Cash Price	$1,286.10
Rate for Payer: Cash Price	$1,286.10
Rate for Payer: Cigna Commercial	$2,134.93
Rate for Payer: First Health Commercial	$2,443.59
Rate for Payer: Humana Commercial	$2,186.37
Rate for Payer: Humana KY Medicaid	$884.58
Rate for Payer: Humana Medicare Advantage	$543.11
Rate for Payer: Kentucky WC Medicaid	$893.58
Rate for Payer: Medical Mutual Of Ohio HMO	$2,109.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,898.28
Rate for Payer: Molina Healthcare Benefit Exchange	$651.73
Rate for Payer: Molina Healthcare Medicaid	$902.33
Rate for Payer: Ohio Health Choice Commercial	$2,263.54
Rate for Payer: Ohio Health Group HMO	$1,929.15
Rate for Payer: Ohio Health Group PPO Differential	$514.44
Rate for Payer: Ohio Health Group PPO No Differential	$334.39
Rate for Payer: Ohio Health Group PPO SOMC Employees	$797.38
Rate for Payer: PHCS Commercial	$2,469.31
Rate for Payer: United Healthcare All Payer	$2,263.54

CORRECT SKN COLOR 6.1-20.0CM

Facility

$2,572.20

Service Code	HCPCS 11921
Hospital Charge Code	76100109
Hospital Revenue Code	761
Min. Negotiated Rate	$334.39
Max. Negotiated Rate	$2,469.31
Rate for Payer: Aetna Commercial	$1,980.59
Rate for Payer: Anthem POS/PPO/Traditional	$2,006.32
Rate for Payer: Cash Price	$1,286.10
Rate for Payer: Cigna Commercial	$2,134.93
Rate for Payer: First Health Commercial	$2,443.59
Rate for Payer: Humana Commercial	$2,186.37
Rate for Payer: Medical Mutual Of Ohio HMO	$2,109.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,898.28
Rate for Payer: Molina Healthcare Benefit Exchange	$771.66
Rate for Payer: Ohio Health Choice Commercial	$2,263.54
Rate for Payer: Ohio Health Group HMO	$1,929.15
Rate for Payer: Ohio Health Group PPO Differential	$514.44
Rate for Payer: Ohio Health Group PPO No Differential	$334.39
Rate for Payer: Ohio Health Group PPO SOMC Employees	$797.38
Rate for Payer: PHCS Commercial	$2,469.31
Rate for Payer: United Healthcare All Payer	$2,263.54

CORRECT SKN COLOR 6.1-20.0CM

Professional

Both

$2,572.20

Service Code	HCPCS 11921
Hospital Charge Code	76100109
Hospital Revenue Code	761
Min. Negotiated Rate	$170.79
Max. Negotiated Rate	$2,572.20
Rate for Payer: Aetna Commercial	$200.57
Rate for Payer: Buckeye Medicare Advantage	$2,572.20
Rate for Payer: Cash Price	$1,286.10
Rate for Payer: Cash Price	$1,286.10
Rate for Payer: Cigna Commercial	$320.43
Rate for Payer: Healthspan PPO	$232.27
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$170.79
Rate for Payer: Multiplan PHCS	$1,543.32
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,800.54
Rate for Payer: UHCCP Medicaid	$900.27

CORRECT SKN COLOR 6.1-20.0C(P

Professional

Both

$1,300.00

Service Code	HCPCS 11921
Hospital Charge Code	761P0109
Hospital Revenue Code	761
Min. Negotiated Rate	$170.79
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$200.57
Rate for Payer: Buckeye Medicare Advantage	$1,300.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$320.43
Rate for Payer: Healthspan PPO	$232.27
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$170.79
Rate for Payer: Multiplan PHCS	$780.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$910.00
Rate for Payer: UHCCP Medicaid	$455.00

CORRECT SKN COLOR 6.1-20.0C(T

Facility

$1,272.20

Service Code	HCPCS 11921
Hospital Charge Code	761T0109
Hospital Revenue Code	761
Min. Negotiated Rate	$165.39
Max. Negotiated Rate	$1,221.31
Rate for Payer: Aetna Commercial	$979.59
Rate for Payer: Anthem POS/PPO/Traditional	$992.32
Rate for Payer: Cash Price	$636.10
Rate for Payer: Cigna Commercial	$1,055.93
Rate for Payer: First Health Commercial	$1,208.59
Rate for Payer: Humana Commercial	$1,081.37
Rate for Payer: Medical Mutual Of Ohio HMO	$1,043.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$938.88
Rate for Payer: Molina Healthcare Benefit Exchange	$381.66
Rate for Payer: Ohio Health Choice Commercial	$1,119.54
Rate for Payer: Ohio Health Group HMO	$954.15
Rate for Payer: Ohio Health Group PPO Differential	$254.44
Rate for Payer: Ohio Health Group PPO No Differential	$165.39
Rate for Payer: Ohio Health Group PPO SOMC Employees	$394.38
Rate for Payer: PHCS Commercial	$1,221.31
Rate for Payer: United Healthcare All Payer	$1,119.54

CORRECT SKN COLOR 6.1-20.0C(T

Facility

$1,272.20

Service Code	HCPCS 11921
Hospital Charge Code	761T0109
Hospital Revenue Code	761
Min. Negotiated Rate	$165.39
Max. Negotiated Rate	$1,221.31
Rate for Payer: Aetna Commercial	$979.59
Rate for Payer: Anthem Medicaid	$437.51
Rate for Payer: Anthem Medicare Advantage/PPO	$543.11
Rate for Payer: Anthem POS/PPO/Traditional	$992.32
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$760.35
Rate for Payer: CareSource Just4Me Medicare	$733.20
Rate for Payer: Cash Price	$636.10
Rate for Payer: Cash Price	$636.10
Rate for Payer: Cigna Commercial	$1,055.93
Rate for Payer: First Health Commercial	$1,208.59
Rate for Payer: Humana Commercial	$1,081.37
Rate for Payer: Humana KY Medicaid	$437.51
Rate for Payer: Humana Medicare Advantage	$543.11
Rate for Payer: Kentucky WC Medicaid	$441.96
Rate for Payer: Medical Mutual Of Ohio HMO	$1,043.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$938.88
Rate for Payer: Molina Healthcare Benefit Exchange	$651.73
Rate for Payer: Molina Healthcare Medicaid	$446.29
Rate for Payer: Ohio Health Choice Commercial	$1,119.54
Rate for Payer: Ohio Health Group HMO	$954.15
Rate for Payer: Ohio Health Group PPO Differential	$254.44
Rate for Payer: Ohio Health Group PPO No Differential	$165.39
Rate for Payer: Ohio Health Group PPO SOMC Employees	$394.38
Rate for Payer: PHCS Commercial	$1,221.31
Rate for Payer: United Healthcare All Payer	$1,119.54

CORRHLLXVALGWSESMDCWPRXMETROST

Professional

Both

$735.00

Service Code	HCPCS 28295
Hospital Charge Code	761P1003
Hospital Revenue Code	761
Min. Negotiated Rate	$430.82
Max. Negotiated Rate	$1,003.40
Rate for Payer: Anthem Medicaid	$430.82
Rate for Payer: Buckeye Medicare Advantage	$735.00
Rate for Payer: Cash Price	$367.50
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$449.70
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cigna Commercial	$1,003.40
Rate for Payer: Humana Medicaid	$430.82
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$705.91
Rate for Payer: Molina Healthcare CHIP/Medicaid	$439.44
Rate for Payer: Molina Healthcare Passport	$430.82
Rate for Payer: Multiplan PHCS	$441.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$514.50
Rate for Payer: UHCCP Medicaid	$472.18
Rate for Payer: Wellcare CHIP/Medicaid	$435.13

CORRHLLXVALGWSESMDCWPRXMETROST

Facility

$735.00

Service Code	HCPCS 28295
Hospital Charge Code	76101003
Hospital Revenue Code	761
Min. Negotiated Rate	$95.55
Max. Negotiated Rate	$3,918.70
Rate for Payer: Aetna Commercial	$565.95
Rate for Payer: Anthem Medicaid	$252.77
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Anthem POS/PPO/Traditional	$573.30
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cigna Commercial	$610.05
Rate for Payer: First Health Commercial	$698.25
Rate for Payer: Humana Commercial	$624.75
Rate for Payer: Humana KY Medicaid	$252.77
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Kentucky WC Medicaid	$255.34
Rate for Payer: Medical Mutual Of Ohio HMO	$602.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$542.43
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88
Rate for Payer: Molina Healthcare Medicaid	$257.84
Rate for Payer: Ohio Health Choice Commercial	$646.80
Rate for Payer: Ohio Health Group HMO	$551.25
Rate for Payer: Ohio Health Group PPO Differential	$147.00
Rate for Payer: Ohio Health Group PPO No Differential	$95.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$227.85
Rate for Payer: PHCS Commercial	$705.60
Rate for Payer: United Healthcare All Payer	$646.80

CORRHLLXVALGWSESMDCWPRXMETROST

Professional

Both

$735.00

Service Code	HCPCS 28295
Hospital Charge Code	76101003
Hospital Revenue Code	761
Min. Negotiated Rate	$430.82
Max. Negotiated Rate	$1,003.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$449.70
Rate for Payer: Anthem Medicaid	$430.82
Rate for Payer: Buckeye Medicare Advantage	$735.00
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cigna Commercial	$1,003.40
Rate for Payer: Humana Medicaid	$430.82
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$705.91
Rate for Payer: Molina Healthcare CHIP/Medicaid	$439.44
Rate for Payer: Molina Healthcare Passport	$430.82
Rate for Payer: Multiplan PHCS	$441.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$514.50
Rate for Payer: UHCCP Medicaid	$472.18
Rate for Payer: Wellcare CHIP/Medicaid	$435.13

CORRHLLXVALGWSESMDCWPRXMETROST

Facility

$735.00

Service Code	HCPCS 28295
Hospital Charge Code	76101003
Hospital Revenue Code	761
Min. Negotiated Rate	$95.55
Max. Negotiated Rate	$705.60
Rate for Payer: Aetna Commercial	$565.95
Rate for Payer: Anthem POS/PPO/Traditional	$573.30
Rate for Payer: Cash Price	$367.50
Rate for Payer: Cigna Commercial	$610.05
Rate for Payer: First Health Commercial	$698.25
Rate for Payer: Humana Commercial	$624.75
Rate for Payer: Medical Mutual Of Ohio HMO	$602.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$542.43
Rate for Payer: Molina Healthcare Benefit Exchange	$220.50
Rate for Payer: Ohio Health Choice Commercial	$646.80
Rate for Payer: Ohio Health Group HMO	$551.25
Rate for Payer: Ohio Health Group PPO Differential	$147.00
Rate for Payer: Ohio Health Group PPO No Differential	$95.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$227.85
Rate for Payer: PHCS Commercial	$705.60
Rate for Payer: United Healthcare All Payer	$646.80

CORR H/V WWO SESMDC W/MET OSTE

Professional

Both

$1,700.00

Service Code	HCPCS 28296
Hospital Charge Code	761P1004
Hospital Revenue Code	761
Min. Negotiated Rate	$314.31
Max. Negotiated Rate	$1,700.00
Rate for Payer: Aetna Commercial	$827.66
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$314.31
Rate for Payer: Anthem Medicaid	$515.11
Rate for Payer: Buckeye Medicare Advantage	$1,700.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cigna Commercial	$964.61
Rate for Payer: Healthspan PPO	$933.42
Rate for Payer: Humana Medicaid	$515.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$649.95
Rate for Payer: Molina Healthcare CHIP/Medicaid	$525.41
Rate for Payer: Molina Healthcare Passport	$515.11
Rate for Payer: Multiplan PHCS	$1,020.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,190.00
Rate for Payer: UHCCP Medicaid	$330.03
Rate for Payer: Wellcare CHIP/Medicaid	$520.26

CORR H/V WWO SESMDC W/MET OSTE

Facility

$1,700.00

Service Code	HCPCS 28296
Hospital Charge Code	76101004
Hospital Revenue Code	761
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$3,918.70
Rate for Payer: Aetna Commercial	$1,309.00
Rate for Payer: Anthem Medicaid	$584.63
Rate for Payer: Anthem Medicare Advantage/PPO	$2,799.07
Rate for Payer: Anthem POS/PPO/Traditional	$1,326.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,918.70
Rate for Payer: CareSource Just4Me Medicare	$3,778.74
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cigna Commercial	$1,411.00
Rate for Payer: First Health Commercial	$1,615.00
Rate for Payer: Humana Commercial	$1,445.00
Rate for Payer: Humana KY Medicaid	$584.63
Rate for Payer: Humana Medicare Advantage	$2,799.07
Rate for Payer: Kentucky WC Medicaid	$590.58
Rate for Payer: Medical Mutual Of Ohio HMO	$1,394.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,254.60
Rate for Payer: Molina Healthcare Benefit Exchange	$3,358.88
Rate for Payer: Molina Healthcare Medicaid	$596.36
Rate for Payer: Ohio Health Choice Commercial	$1,496.00
Rate for Payer: Ohio Health Group HMO	$1,275.00
Rate for Payer: Ohio Health Group PPO Differential	$340.00
Rate for Payer: Ohio Health Group PPO No Differential	$221.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$527.00
Rate for Payer: PHCS Commercial	$1,632.00
Rate for Payer: United Healthcare All Payer	$1,496.00

CORR H/V WWO SESMDC W/MET OSTE

Facility

$1,700.00

Service Code	HCPCS 28296
Hospital Charge Code	76101004
Hospital Revenue Code	761
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$1,632.00
Rate for Payer: Aetna Commercial	$1,309.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,326.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cigna Commercial	$1,411.00
Rate for Payer: First Health Commercial	$1,615.00
Rate for Payer: Humana Commercial	$1,445.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,394.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,254.60
Rate for Payer: Molina Healthcare Benefit Exchange	$510.00
Rate for Payer: Ohio Health Choice Commercial	$1,496.00
Rate for Payer: Ohio Health Group HMO	$1,275.00
Rate for Payer: Ohio Health Group PPO Differential	$340.00
Rate for Payer: Ohio Health Group PPO No Differential	$221.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$527.00
Rate for Payer: PHCS Commercial	$1,632.00
Rate for Payer: United Healthcare All Payer	$1,496.00

CORR H/V WWO SESMDC W/MET OSTE

Professional

Both

$1,700.00

Service Code	HCPCS 28296
Hospital Charge Code	76101004
Hospital Revenue Code	761
Min. Negotiated Rate	$314.31
Max. Negotiated Rate	$1,700.00
Rate for Payer: Aetna Commercial	$827.66
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$314.31
Rate for Payer: Anthem Medicaid	$515.11
Rate for Payer: Buckeye Medicare Advantage	$1,700.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cash Price	$850.00
Rate for Payer: Cigna Commercial	$964.61
Rate for Payer: Healthspan PPO	$933.42
Rate for Payer: Humana Medicaid	$515.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$649.95
Rate for Payer: Molina Healthcare CHIP/Medicaid	$525.41
Rate for Payer: Molina Healthcare Passport	$515.11
Rate for Payer: Multiplan PHCS	$1,020.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,190.00
Rate for Payer: UHCCP Medicaid	$330.03
Rate for Payer: Wellcare CHIP/Medicaid	$520.26

CORRJ HALUX RIGDUS W/O IMPL(P

Professional

Both

$1,750.00

Service Code	HCPCS 28289
Hospital Charge Code	761P1002
Hospital Revenue Code	761
Min. Negotiated Rate	$233.42
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$830.34
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$233.42
Rate for Payer: Anthem Medicaid	$284.76
Rate for Payer: Buckeye Medicare Advantage	$1,750.00
Rate for Payer: Cash Price	$875.00
Rate for Payer: Cash Price	$875.00
Rate for Payer: Cigna Commercial	$905.96
Rate for Payer: Healthspan PPO	$921.30
Rate for Payer: Humana Medicaid	$284.76
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$683.72
Rate for Payer: Molina Healthcare CHIP/Medicaid	$290.46
Rate for Payer: Molina Healthcare Passport	$284.76
Rate for Payer: Multiplan PHCS	$1,050.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,225.00
Rate for Payer: UHCCP Medicaid	$245.09
Rate for Payer: Wellcare CHIP/Medicaid	$287.61

Know your out-of-pocket cost for care.

All Charges