Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CUP RESTORATION ADM 64MM LEFT

Facility

$17,083.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$5,125.08
Max. Negotiated Rate	$16,400.26
Rate for Payer: Aetna Commercial	$13,154.37
Rate for Payer: Anthem POS/PPO/Traditional	$13,325.21
Rate for Payer: Cash Price	$8,541.80
Rate for Payer: Cigna Commercial	$14,179.39
Rate for Payer: First Health Commercial	$16,229.42
Rate for Payer: Humana Commercial	$14,521.06
Rate for Payer: Medical Mutual Of Ohio HMO	$14,008.55
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,607.70
Rate for Payer: Molina Healthcare Benefit Exchange	$5,125.08
Rate for Payer: Ohio Health Choice Commercial	$15,033.57
Rate for Payer: Ohio Health Group HMO	$12,812.70
Rate for Payer: Ohio Health Group PPO Differential	$13,666.88
Rate for Payer: Ohio Health Group PPO No Differential	$14,862.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,787.68
Rate for Payer: PHCS Commercial	$16,400.26
Rate for Payer: United Healthcare All Payer	$15,033.57

CUP RESTORATION ADM 64MM LEFT

Facility

$17,083.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$5,125.08
Max. Negotiated Rate	$16,400.26
Rate for Payer: Aetna Commercial	$13,154.37
Rate for Payer: Anthem Medicaid	$5,875.05
Rate for Payer: Anthem POS/PPO/Traditional	$13,325.21
Rate for Payer: Cash Price	$8,541.80
Rate for Payer: Cigna Commercial	$14,179.39
Rate for Payer: First Health Commercial	$16,229.42
Rate for Payer: Humana Commercial	$14,521.06
Rate for Payer: Humana KY Medicaid	$5,875.05
Rate for Payer: Kentucky WC Medicaid	$5,934.84
Rate for Payer: Medical Mutual Of Ohio HMO	$14,008.55
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,607.70
Rate for Payer: Molina Healthcare Benefit Exchange	$5,125.08
Rate for Payer: Molina Healthcare Medicaid	$5,992.93
Rate for Payer: Ohio Health Choice Commercial	$15,033.57
Rate for Payer: Ohio Health Group HMO	$12,812.70
Rate for Payer: Ohio Health Group PPO Differential	$13,666.88
Rate for Payer: Ohio Health Group PPO No Differential	$14,862.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,787.68
Rate for Payer: PHCS Commercial	$16,400.26
Rate for Payer: United Healthcare All Payer	$15,033.57

CUP RESTORATION ADM 64MM RIGHT

Facility

$17,083.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$5,125.08
Max. Negotiated Rate	$16,400.26
Rate for Payer: Aetna Commercial	$13,154.37
Rate for Payer: Anthem Medicaid	$5,875.05
Rate for Payer: Anthem POS/PPO/Traditional	$13,325.21
Rate for Payer: Cash Price	$8,541.80
Rate for Payer: Cigna Commercial	$14,179.39
Rate for Payer: First Health Commercial	$16,229.42
Rate for Payer: Humana Commercial	$14,521.06
Rate for Payer: Humana KY Medicaid	$5,875.05
Rate for Payer: Kentucky WC Medicaid	$5,934.84
Rate for Payer: Medical Mutual Of Ohio HMO	$14,008.55
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,607.70
Rate for Payer: Molina Healthcare Benefit Exchange	$5,125.08
Rate for Payer: Molina Healthcare Medicaid	$5,992.93
Rate for Payer: Ohio Health Choice Commercial	$15,033.57
Rate for Payer: Ohio Health Group HMO	$12,812.70
Rate for Payer: Ohio Health Group PPO Differential	$13,666.88
Rate for Payer: Ohio Health Group PPO No Differential	$14,862.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,787.68
Rate for Payer: PHCS Commercial	$16,400.26
Rate for Payer: United Healthcare All Payer	$15,033.57

CUP RESTORATION ADM 64MM RIGHT

Facility

$17,083.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$5,125.08
Max. Negotiated Rate	$16,400.26
Rate for Payer: Aetna Commercial	$13,154.37
Rate for Payer: Anthem POS/PPO/Traditional	$13,325.21
Rate for Payer: Cash Price	$8,541.80
Rate for Payer: Cigna Commercial	$14,179.39
Rate for Payer: First Health Commercial	$16,229.42
Rate for Payer: Humana Commercial	$14,521.06
Rate for Payer: Medical Mutual Of Ohio HMO	$14,008.55
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,607.70
Rate for Payer: Molina Healthcare Benefit Exchange	$5,125.08
Rate for Payer: Ohio Health Choice Commercial	$15,033.57
Rate for Payer: Ohio Health Group HMO	$12,812.70
Rate for Payer: Ohio Health Group PPO Differential	$13,666.88
Rate for Payer: Ohio Health Group PPO No Differential	$14,862.73
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,787.68
Rate for Payer: PHCS Commercial	$16,400.26
Rate for Payer: United Healthcare All Payer	$15,033.57

CUP TRID 2 CLSTRHOLE HA 46C

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 46C

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 48D

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 48D

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 50D

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 50D

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 52E

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 52E

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 54E

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 54E

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 56F

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 56F

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 58F

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 58F

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 60G

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 60G

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 62G

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem Medicaid	$2,914.55
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Humana KY Medicaid	$2,914.55
Rate for Payer: Kentucky WC Medicaid	$2,944.22
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Molina Healthcare Medicaid	$2,973.03
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP TRID 2 CLSTRHOLE HA 62G

Facility

$8,475.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.50
Max. Negotiated Rate	$8,136.00
Rate for Payer: Aetna Commercial	$6,525.75
Rate for Payer: Anthem POS/PPO/Traditional	$6,610.50
Rate for Payer: Cash Price	$4,237.50
Rate for Payer: Cigna Commercial	$7,034.25
Rate for Payer: First Health Commercial	$8,051.25
Rate for Payer: Humana Commercial	$7,203.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,949.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,254.55
Rate for Payer: Molina Healthcare Benefit Exchange	$2,542.50
Rate for Payer: Ohio Health Choice Commercial	$7,458.00
Rate for Payer: Ohio Health Group HMO	$6,356.25
Rate for Payer: Ohio Health Group PPO Differential	$6,780.00
Rate for Payer: Ohio Health Group PPO No Differential	$7,373.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,847.75
Rate for Payer: PHCS Commercial	$8,136.00
Rate for Payer: United Healthcare All Payer	$7,458.00

CUP UNIV 2H SHL 40MM S20

Facility

$7,380.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,214.00
Max. Negotiated Rate	$7,084.80
Rate for Payer: Aetna Commercial	$5,682.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,756.40
Rate for Payer: Cash Price	$3,690.00
Rate for Payer: Cigna Commercial	$6,125.40
Rate for Payer: First Health Commercial	$7,011.00
Rate for Payer: Humana Commercial	$6,273.00
Rate for Payer: Medical Mutual Of Ohio HMO	$6,051.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,446.44
Rate for Payer: Molina Healthcare Benefit Exchange	$2,214.00
Rate for Payer: Ohio Health Choice Commercial	$6,494.40
Rate for Payer: Ohio Health Group HMO	$5,535.00
Rate for Payer: Ohio Health Group PPO Differential	$5,904.00
Rate for Payer: Ohio Health Group PPO No Differential	$6,420.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,092.20
Rate for Payer: PHCS Commercial	$7,084.80
Rate for Payer: United Healthcare All Payer	$6,494.40

CUP UNIV 2H SHL 40MM S20

Facility

$7,380.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,214.00
Max. Negotiated Rate	$7,084.80
Rate for Payer: Aetna Commercial	$5,682.60
Rate for Payer: Anthem Medicaid	$2,537.98
Rate for Payer: Anthem POS/PPO/Traditional	$5,756.40
Rate for Payer: Cash Price	$3,690.00
Rate for Payer: Cigna Commercial	$6,125.40
Rate for Payer: First Health Commercial	$7,011.00
Rate for Payer: Humana Commercial	$6,273.00
Rate for Payer: Humana KY Medicaid	$2,537.98
Rate for Payer: Kentucky WC Medicaid	$2,563.81
Rate for Payer: Medical Mutual Of Ohio HMO	$6,051.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,446.44
Rate for Payer: Molina Healthcare Benefit Exchange	$2,214.00
Rate for Payer: Molina Healthcare Medicaid	$2,588.90
Rate for Payer: Ohio Health Choice Commercial	$6,494.40
Rate for Payer: Ohio Health Group HMO	$5,535.00
Rate for Payer: Ohio Health Group PPO Differential	$5,904.00
Rate for Payer: Ohio Health Group PPO No Differential	$6,420.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,092.20
Rate for Payer: PHCS Commercial	$7,084.80
Rate for Payer: United Healthcare All Payer	$6,494.40

CUP UNIV 2H SHL 42MM S20

Facility

$7,380.00

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$2,214.00
Max. Negotiated Rate	$7,084.80
Rate for Payer: Aetna Commercial	$5,682.60
Rate for Payer: Anthem POS/PPO/Traditional	$5,756.40
Rate for Payer: Cash Price	$3,690.00
Rate for Payer: Cigna Commercial	$6,125.40
Rate for Payer: First Health Commercial	$7,011.00
Rate for Payer: Humana Commercial	$6,273.00
Rate for Payer: Medical Mutual Of Ohio HMO	$6,051.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,446.44
Rate for Payer: Molina Healthcare Benefit Exchange	$2,214.00
Rate for Payer: Ohio Health Choice Commercial	$6,494.40
Rate for Payer: Ohio Health Group HMO	$5,535.00
Rate for Payer: Ohio Health Group PPO Differential	$5,904.00
Rate for Payer: Ohio Health Group PPO No Differential	$6,420.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$5,092.20
Rate for Payer: PHCS Commercial	$7,084.80
Rate for Payer: United Healthcare All Payer	$6,494.40

Know your out-of-pocket cost for care.

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