Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$4,921.43

Service Code	CPT 43261
Hospital Revenue Code	360
Min. Negotiated Rate	$3,515.31
Max. Negotiated Rate	$4,921.43
Rate for Payer: Anthem Medicare Advantage/PPO	$3,515.31
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,921.43
Rate for Payer: CareSource Just4Me Medicare	$4,745.67
Rate for Payer: Humana Medicare Advantage	$3,515.31
Rate for Payer: Molina Healthcare Benefit Exchange	$4,218.37

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT

Facility

$7,700.39

Service Code	CPT 43274
Hospital Revenue Code	360
Min. Negotiated Rate	$5,500.28
Max. Negotiated Rate	$7,700.39
Rate for Payer: Anthem Medicare Advantage/PPO	$5,500.28
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,700.39
Rate for Payer: CareSource Just4Me Medicare	$7,425.38
Rate for Payer: Humana Medicare Advantage	$5,500.28
Rate for Payer: Molina Healthcare Benefit Exchange	$6,600.34

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED

Facility

$7,700.39

Service Code	CPT 43276
Hospital Revenue Code	360
Min. Negotiated Rate	$5,500.28
Max. Negotiated Rate	$7,700.39
Rate for Payer: Anthem Medicare Advantage/PPO	$5,500.28
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,700.39
Rate for Payer: CareSource Just4Me Medicare	$7,425.38
Rate for Payer: Humana Medicare Advantage	$5,500.28
Rate for Payer: Molina Healthcare Benefit Exchange	$6,600.34

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S)

Facility

$4,921.43

Service Code	CPT 43264
Hospital Revenue Code	360
Min. Negotiated Rate	$3,515.31
Max. Negotiated Rate	$4,921.43
Rate for Payer: Anthem Medicare Advantage/PPO	$3,515.31
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,921.43
Rate for Payer: CareSource Just4Me Medicare	$4,745.67
Rate for Payer: Humana Medicare Advantage	$3,515.31
Rate for Payer: Molina Healthcare Benefit Exchange	$4,218.37

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S)

Facility

$2,453.89

Service Code	CPT 43275
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY

Facility

$4,921.43

Service Code	CPT 43262
Hospital Revenue Code	360
Min. Negotiated Rate	$3,515.31
Max. Negotiated Rate	$4,921.43
Rate for Payer: Anthem Medicare Advantage/PPO	$3,515.31
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,921.43
Rate for Payer: CareSource Just4Me Medicare	$4,745.67
Rate for Payer: Humana Medicare Advantage	$3,515.31
Rate for Payer: Molina Healthcare Benefit Exchange	$4,218.37

ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD), INCLUDING ENDOSCOPY OR COLONOSCOPY, MUCOSAL CLOSURE, WHEN PERFORMED

Facility

$4,921.43

Service Code	CPT C9779
Hospital Revenue Code	360
Min. Negotiated Rate	$3,515.31
Max. Negotiated Rate	$4,921.43
Rate for Payer: Anthem Medicare Advantage/PPO	$3,515.31
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,921.43
Rate for Payer: CareSource Just4Me Medicare	$4,745.67
Rate for Payer: Humana Medicare Advantage	$3,515.31
Rate for Payer: Molina Healthcare Benefit Exchange	$4,218.37

ENDOSCOPY MAXILLARY SINUS

Professional

Both

$1,900.00

Service Code	HCPCS 31267
Hospital Charge Code	76101156
Hospital Revenue Code	761
Min. Negotiated Rate	$249.80
Max. Negotiated Rate	$1,140.00
Rate for Payer: Aetna Commercial	$491.34
Rate for Payer: Ambetter Exchange	$249.80
Rate for Payer: Anthem Medicaid	$320.18
Rate for Payer: Buckeye Individual/Medicaid	$249.80
Rate for Payer: Buckeye Medicare Advantage	$249.80
Rate for Payer: CareSource Just4Me Medicare	$299.76
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cigna Commercial	$496.31
Rate for Payer: Healthspan PPO	$414.36
Rate for Payer: Humana Medicaid	$320.18
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$415.64
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$249.80
Rate for Payer: Molina Healthcare Benefit Exchange	$249.80
Rate for Payer: Molina Healthcare CHIP/Medicaid	$326.58
Rate for Payer: Molina Healthcare Passport	$320.18
Rate for Payer: Multiplan PHCS	$1,140.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$324.74
Rate for Payer: UHCCP Medicaid	$665.00
Rate for Payer: Wellcare CHIP/Medicaid	$323.38
Rate for Payer: Wellcare Medicare Advantage	$249.80

ENDOSCOPY MAXILLARY SINUS

Facility

$1,900.00

Service Code	HCPCS 31267
Hospital Charge Code	76101156
Hospital Revenue Code	761
Min. Negotiated Rate	$653.41
Max. Negotiated Rate	$8,954.71
Rate for Payer: Aetna Commercial	$1,463.00
Rate for Payer: Anthem Medicaid	$653.41
Rate for Payer: Anthem Medicare Advantage/PPO	$6,396.22
Rate for Payer: Anthem POS/PPO/Traditional	$1,482.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,954.71
Rate for Payer: CareSource Just4Me Medicare	$8,634.90
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cigna Commercial	$1,577.00
Rate for Payer: First Health Commercial	$1,805.00
Rate for Payer: Humana Commercial	$1,615.00
Rate for Payer: Humana KY Medicaid	$653.41
Rate for Payer: Humana Medicare Advantage	$6,396.22
Rate for Payer: Kentucky WC Medicaid	$660.06
Rate for Payer: Medical Mutual Of Ohio HMO	$1,558.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,402.20
Rate for Payer: Molina Healthcare Benefit Exchange	$7,675.46
Rate for Payer: Molina Healthcare Medicaid	$666.52
Rate for Payer: Ohio Health Choice Commercial	$1,672.00
Rate for Payer: Ohio Health Group HMO	$1,425.00
Rate for Payer: Ohio Health Group PPO Differential	$1,520.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,653.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,311.00
Rate for Payer: PHCS Commercial	$1,824.00
Rate for Payer: United Healthcare All Payer	$1,672.00

ENDOSCOPY MAXILLARY SINUS

Facility

$1,900.00

Service Code	HCPCS 31267
Hospital Charge Code	76101156
Hospital Revenue Code	761
Min. Negotiated Rate	$570.00
Max. Negotiated Rate	$1,824.00
Rate for Payer: Aetna Commercial	$1,463.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,482.00
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cigna Commercial	$1,577.00
Rate for Payer: First Health Commercial	$1,805.00
Rate for Payer: Humana Commercial	$1,615.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,558.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,402.20
Rate for Payer: Molina Healthcare Benefit Exchange	$570.00
Rate for Payer: Ohio Health Choice Commercial	$1,672.00
Rate for Payer: Ohio Health Group HMO	$1,425.00
Rate for Payer: Ohio Health Group PPO Differential	$1,520.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,653.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,311.00
Rate for Payer: PHCS Commercial	$1,824.00
Rate for Payer: United Healthcare All Payer	$1,672.00

ENDOSCOPY MAXILLARY SINUS(P

Professional

Both

$1,900.00

Service Code	HCPCS 31267
Hospital Charge Code	761P1156
Hospital Revenue Code	761
Min. Negotiated Rate	$249.80
Max. Negotiated Rate	$1,140.00
Rate for Payer: Aetna Commercial	$491.34
Rate for Payer: Ambetter Exchange	$249.80
Rate for Payer: Anthem Medicaid	$320.18
Rate for Payer: Buckeye Individual/Medicaid	$249.80
Rate for Payer: Buckeye Medicare Advantage	$249.80
Rate for Payer: CareSource Just4Me Medicare	$299.76
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cash Price	$950.00
Rate for Payer: Cigna Commercial	$496.31
Rate for Payer: Healthspan PPO	$414.36
Rate for Payer: Humana Medicaid	$320.18
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$415.64
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$249.80
Rate for Payer: Molina Healthcare Benefit Exchange	$249.80
Rate for Payer: Molina Healthcare CHIP/Medicaid	$326.58
Rate for Payer: Molina Healthcare Passport	$320.18
Rate for Payer: Multiplan PHCS	$1,140.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$324.74
Rate for Payer: UHCCP Medicaid	$665.00
Rate for Payer: Wellcare CHIP/Medicaid	$323.38
Rate for Payer: Wellcare Medicare Advantage	$249.80

ENDOSCOPY OF BOWEL POUCH

Professional

Both

$175.00

Service Code	HCPCS 44385
Hospital Charge Code	76102999
Hospital Revenue Code	761
Min. Negotiated Rate	$68.03
Max. Negotiated Rate	$310.99
Rate for Payer: Aetna Commercial	$161.78
Rate for Payer: Ambetter Exchange	$68.03
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$73.71
Rate for Payer: Anthem Medicaid	$124.16
Rate for Payer: Buckeye Individual/Medicaid	$68.03
Rate for Payer: Buckeye Medicare Advantage	$68.03
Rate for Payer: CareSource Just4Me Medicare	$81.64
Rate for Payer: Cash Price	$87.50
Rate for Payer: Cash Price	$87.50
Rate for Payer: Cigna Commercial	$310.99
Rate for Payer: Healthspan PPO	$296.20
Rate for Payer: Humana Medicaid	$124.16
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$137.80
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$68.03
Rate for Payer: Molina Healthcare Benefit Exchange	$68.03
Rate for Payer: Molina Healthcare CHIP/Medicaid	$126.64
Rate for Payer: Molina Healthcare Passport	$124.16
Rate for Payer: Multiplan PHCS	$105.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$88.44
Rate for Payer: UHCCP Medicaid	$77.40
Rate for Payer: Wellcare CHIP/Medicaid	$125.40
Rate for Payer: Wellcare Medicare Advantage	$68.03

ENDOTRACHEAL TUBE EXCHANGE

Professional

Both

$218.00

Service Code	HCPCS 31599
Hospital Charge Code	76102737
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$470.07
Rate for Payer: Anthem Medicaid	$460.85
Rate for Payer: Cash Price	$109.00
Rate for Payer: Cash Price	$109.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$460.85
Rate for Payer: Molina Healthcare CHIP/Medicaid	$470.07
Rate for Payer: Molina Healthcare Passport	$460.85
Rate for Payer: Multiplan PHCS	$130.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$152.60
Rate for Payer: UHCCP Medicaid	$76.30
Rate for Payer: Wellcare CHIP/Medicaid	$465.46

ENDOVASC VISC AORTA 1 GRAFT

Facility

$2,700.00

Service Code	HCPCS 34841
Hospital Charge Code	76101353
Hospital Revenue Code	761
Min. Negotiated Rate	$810.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna Commercial	$2,079.00
Rate for Payer: Anthem Medicaid	$928.53
Rate for Payer: Anthem POS/PPO/Traditional	$2,106.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cigna Commercial	$2,241.00
Rate for Payer: First Health Commercial	$2,565.00
Rate for Payer: Humana Commercial	$2,295.00
Rate for Payer: Humana KY Medicaid	$928.53
Rate for Payer: Kentucky WC Medicaid	$937.98
Rate for Payer: Medical Mutual Of Ohio HMO	$2,214.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,992.60
Rate for Payer: Molina Healthcare Benefit Exchange	$810.00
Rate for Payer: Molina Healthcare Medicaid	$947.16
Rate for Payer: Ohio Health Choice Commercial	$2,376.00
Rate for Payer: Ohio Health Group HMO	$2,025.00
Rate for Payer: Ohio Health Group PPO Differential	$2,160.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,349.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,863.00
Rate for Payer: PHCS Commercial	$2,592.00
Rate for Payer: United Healthcare All Payer	$2,376.00

ENDOVASC VISC AORTA 1 GRAFT

Professional

Both

$2,700.00

Service Code	HCPCS 34841
Hospital Charge Code	76101353
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,890.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,515.61
Rate for Payer: Multiplan PHCS	$1,620.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,890.00
Rate for Payer: UHCCP Medicaid	$945.00

ENDOVASC VISC AORTA 1 GRAFT

Facility

$2,700.00

Service Code	HCPCS 34841
Hospital Charge Code	76101353
Hospital Revenue Code	761
Min. Negotiated Rate	$810.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna Commercial	$2,079.00
Rate for Payer: Anthem POS/PPO/Traditional	$2,106.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cigna Commercial	$2,241.00
Rate for Payer: First Health Commercial	$2,565.00
Rate for Payer: Humana Commercial	$2,295.00
Rate for Payer: Medical Mutual Of Ohio HMO	$2,214.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,992.60
Rate for Payer: Molina Healthcare Benefit Exchange	$810.00
Rate for Payer: Ohio Health Choice Commercial	$2,376.00
Rate for Payer: Ohio Health Group HMO	$2,025.00
Rate for Payer: Ohio Health Group PPO Differential	$2,160.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,349.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,863.00
Rate for Payer: PHCS Commercial	$2,592.00
Rate for Payer: United Healthcare All Payer	$2,376.00

ENDOVASC VISC AORTA 1 GRAFT(P

Professional

Both

$2,700.00

Service Code	HCPCS 34841
Hospital Charge Code	761P1353
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,890.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,515.61
Rate for Payer: Multiplan PHCS	$1,620.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,890.00
Rate for Payer: UHCCP Medicaid	$945.00

ENDOVENOUS 1ST VEIN

Facility

$9,643.50

Service Code	HCPCS 36475
Hospital Charge Code	76101464
Hospital Revenue Code	761
Min. Negotiated Rate	$2,908.23
Max. Negotiated Rate	$9,257.76
Rate for Payer: Aetna Commercial	$7,425.49
Rate for Payer: Anthem Medicaid	$3,316.40
Rate for Payer: Anthem Medicare Advantage/PPO	$2,908.23
Rate for Payer: Anthem POS/PPO/Traditional	$7,521.93
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,071.52
Rate for Payer: CareSource Just4Me Medicare	$3,926.11
Rate for Payer: Cash Price	$4,821.75
Rate for Payer: Cash Price	$4,821.75
Rate for Payer: Cigna Commercial	$8,004.10
Rate for Payer: First Health Commercial	$9,161.33
Rate for Payer: Humana Commercial	$8,196.98
Rate for Payer: Humana KY Medicaid	$3,316.40
Rate for Payer: Humana Medicare Advantage	$2,908.23
Rate for Payer: Kentucky WC Medicaid	$3,350.15
Rate for Payer: Medical Mutual Of Ohio HMO	$7,907.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,116.90
Rate for Payer: Molina Healthcare Benefit Exchange	$3,489.88
Rate for Payer: Molina Healthcare Medicaid	$3,382.94
Rate for Payer: Ohio Health Choice Commercial	$8,486.28
Rate for Payer: Ohio Health Group HMO	$7,232.62
Rate for Payer: Ohio Health Group PPO Differential	$7,714.80
Rate for Payer: Ohio Health Group PPO No Differential	$8,389.84
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,654.02
Rate for Payer: PHCS Commercial	$9,257.76
Rate for Payer: United Healthcare All Payer	$8,486.28

ENDOVENOUS 1ST VEIN

Facility

$9,643.50

Service Code	HCPCS 36475
Hospital Charge Code	76101464
Hospital Revenue Code	761
Min. Negotiated Rate	$2,893.05
Max. Negotiated Rate	$9,257.76
Rate for Payer: Aetna Commercial	$7,425.49
Rate for Payer: Anthem POS/PPO/Traditional	$7,521.93
Rate for Payer: Cash Price	$4,821.75
Rate for Payer: Cigna Commercial	$8,004.10
Rate for Payer: First Health Commercial	$9,161.33
Rate for Payer: Humana Commercial	$8,196.98
Rate for Payer: Medical Mutual Of Ohio HMO	$7,907.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,116.90
Rate for Payer: Molina Healthcare Benefit Exchange	$2,893.05
Rate for Payer: Ohio Health Choice Commercial	$8,486.28
Rate for Payer: Ohio Health Group HMO	$7,232.62
Rate for Payer: Ohio Health Group PPO Differential	$7,714.80
Rate for Payer: Ohio Health Group PPO No Differential	$8,389.84
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,654.02
Rate for Payer: PHCS Commercial	$9,257.76
Rate for Payer: United Healthcare All Payer	$8,486.28

ENDOVENOUS 1ST VEIN

Professional

Both

$9,643.50

Service Code	HCPCS 36475
Hospital Charge Code	76101464
Hospital Revenue Code	761
Min. Negotiated Rate	$260.25
Max. Negotiated Rate	$5,786.10
Rate for Payer: Aetna Commercial	$532.05
Rate for Payer: Ambetter Exchange	$260.25
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$271.17
Rate for Payer: Anthem Medicaid	$1,379.06
Rate for Payer: Buckeye Individual/Medicaid	$260.25
Rate for Payer: Buckeye Medicare Advantage	$260.25
Rate for Payer: CareSource Just4Me Medicare	$312.30
Rate for Payer: Cash Price	$4,821.75
Rate for Payer: Cash Price	$4,821.75
Rate for Payer: Cigna Commercial	$3,000.73
Rate for Payer: Healthspan PPO	$2,043.51
Rate for Payer: Humana Medicaid	$1,379.06
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$470.21
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$260.25
Rate for Payer: Molina Healthcare Benefit Exchange	$260.25
Rate for Payer: Molina Healthcare CHIP/Medicaid	$1,406.64
Rate for Payer: Molina Healthcare Passport	$1,379.06
Rate for Payer: Multiplan PHCS	$5,786.10
Rate for Payer: Ohio Health Choice Preferred Health Choice	$338.32
Rate for Payer: UHCCP Medicaid	$284.73
Rate for Payer: Wellcare CHIP/Medicaid	$1,392.85
Rate for Payer: Wellcare Medicare Advantage	$260.25

ENDOVENOUS 1ST VEIN(P

Professional

Both

$3,000.00

Service Code	HCPCS 36475
Hospital Charge Code	761P1464
Hospital Revenue Code	761
Min. Negotiated Rate	$260.25
Max. Negotiated Rate	$3,000.73
Rate for Payer: Aetna Commercial	$532.05
Rate for Payer: Ambetter Exchange	$260.25
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$271.17
Rate for Payer: Anthem Medicaid	$1,379.06
Rate for Payer: Buckeye Individual/Medicaid	$260.25
Rate for Payer: Buckeye Medicare Advantage	$260.25
Rate for Payer: CareSource Just4Me Medicare	$312.30
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Cash Price	$1,500.00
Rate for Payer: Cigna Commercial	$3,000.73
Rate for Payer: Healthspan PPO	$2,043.51
Rate for Payer: Humana Medicaid	$1,379.06
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$470.21
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$260.25
Rate for Payer: Molina Healthcare Benefit Exchange	$260.25
Rate for Payer: Molina Healthcare CHIP/Medicaid	$1,406.64
Rate for Payer: Molina Healthcare Passport	$1,379.06
Rate for Payer: Multiplan PHCS	$1,800.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$338.32
Rate for Payer: UHCCP Medicaid	$284.73
Rate for Payer: Wellcare CHIP/Medicaid	$1,392.85
Rate for Payer: Wellcare Medicare Advantage	$260.25

ENDOVENOUS 1ST VEIN(T

Facility

$6,643.50

Service Code	HCPCS 36475
Hospital Charge Code	761T1464
Hospital Revenue Code	761
Min. Negotiated Rate	$1,993.05
Max. Negotiated Rate	$6,377.76
Rate for Payer: Aetna Commercial	$5,115.49
Rate for Payer: Anthem POS/PPO/Traditional	$5,181.93
Rate for Payer: Cash Price	$3,321.75
Rate for Payer: Cigna Commercial	$5,514.10
Rate for Payer: First Health Commercial	$6,311.32
Rate for Payer: Humana Commercial	$5,646.98
Rate for Payer: Medical Mutual Of Ohio HMO	$5,447.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,902.90
Rate for Payer: Molina Healthcare Benefit Exchange	$1,993.05
Rate for Payer: Ohio Health Choice Commercial	$5,846.28
Rate for Payer: Ohio Health Group HMO	$4,982.62
Rate for Payer: Ohio Health Group PPO Differential	$5,314.80
Rate for Payer: Ohio Health Group PPO No Differential	$5,779.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,584.02
Rate for Payer: PHCS Commercial	$6,377.76
Rate for Payer: United Healthcare All Payer	$5,846.28

ENDOVENOUS 1ST VEIN(T

Facility

$6,643.50

Service Code	HCPCS 36475
Hospital Charge Code	761T1464
Hospital Revenue Code	761
Min. Negotiated Rate	$2,284.70
Max. Negotiated Rate	$6,377.76
Rate for Payer: Aetna Commercial	$5,115.49
Rate for Payer: Anthem Medicaid	$2,284.70
Rate for Payer: Anthem Medicare Advantage/PPO	$2,908.23
Rate for Payer: Anthem POS/PPO/Traditional	$5,181.93
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,071.52
Rate for Payer: CareSource Just4Me Medicare	$3,926.11
Rate for Payer: Cash Price	$3,321.75
Rate for Payer: Cash Price	$3,321.75
Rate for Payer: Cigna Commercial	$5,514.10
Rate for Payer: First Health Commercial	$6,311.32
Rate for Payer: Humana Commercial	$5,646.98
Rate for Payer: Humana KY Medicaid	$2,284.70
Rate for Payer: Humana Medicare Advantage	$2,908.23
Rate for Payer: Kentucky WC Medicaid	$2,307.95
Rate for Payer: Medical Mutual Of Ohio HMO	$5,447.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,902.90
Rate for Payer: Molina Healthcare Benefit Exchange	$3,489.88
Rate for Payer: Molina Healthcare Medicaid	$2,330.54
Rate for Payer: Ohio Health Choice Commercial	$5,846.28
Rate for Payer: Ohio Health Group HMO	$4,982.62
Rate for Payer: Ohio Health Group PPO Differential	$5,314.80
Rate for Payer: Ohio Health Group PPO No Differential	$5,779.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,584.02
Rate for Payer: PHCS Commercial	$6,377.76
Rate for Payer: United Healthcare All Payer	$5,846.28

ENDOVENOUS ABLATION

Professional

Both

$4,307.52

Service Code	HCPCS 36476
Hospital Charge Code	76101465
Hospital Revenue Code	761
Min. Negotiated Rate	$125.73
Max. Negotiated Rate	$2,584.51
Rate for Payer: Aetna Commercial	$260.41
Rate for Payer: Ambetter Exchange	$125.73
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$126.27
Rate for Payer: Anthem Medicaid	$306.01
Rate for Payer: Buckeye Individual/Medicaid	$125.73
Rate for Payer: Buckeye Medicare Advantage	$125.73
Rate for Payer: CareSource Just4Me Medicare	$150.88
Rate for Payer: Cash Price	$2,153.76
Rate for Payer: Cash Price	$2,153.76
Rate for Payer: Cigna Commercial	$597.19
Rate for Payer: Healthspan PPO	$447.44
Rate for Payer: Humana Medicaid	$306.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$230.55
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$125.73
Rate for Payer: Molina Healthcare Benefit Exchange	$125.73
Rate for Payer: Molina Healthcare CHIP/Medicaid	$312.13
Rate for Payer: Molina Healthcare Passport	$306.01
Rate for Payer: Multiplan PHCS	$2,584.51
Rate for Payer: Ohio Health Choice Preferred Health Choice	$163.45
Rate for Payer: UHCCP Medicaid	$132.58
Rate for Payer: Wellcare CHIP/Medicaid	$309.07
Rate for Payer: Wellcare Medicare Advantage	$125.73

ENDOVENOUS ABLATION

Facility

$4,307.52

Service Code	HCPCS 36476
Hospital Charge Code	76101465
Hospital Revenue Code	761
Min. Negotiated Rate	$1,292.26
Max. Negotiated Rate	$4,135.22
Rate for Payer: Aetna Commercial	$3,316.79
Rate for Payer: Anthem Medicaid	$1,481.36
Rate for Payer: Anthem POS/PPO/Traditional	$3,359.87
Rate for Payer: Cash Price	$2,153.76
Rate for Payer: Cigna Commercial	$3,575.24
Rate for Payer: First Health Commercial	$4,092.14
Rate for Payer: Humana Commercial	$3,661.39
Rate for Payer: Humana KY Medicaid	$1,481.36
Rate for Payer: Kentucky WC Medicaid	$1,496.43
Rate for Payer: Medical Mutual Of Ohio HMO	$3,532.17
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,178.95
Rate for Payer: Molina Healthcare Benefit Exchange	$1,292.26
Rate for Payer: Molina Healthcare Medicaid	$1,511.08
Rate for Payer: Ohio Health Choice Commercial	$3,790.62
Rate for Payer: Ohio Health Group HMO	$3,230.64
Rate for Payer: Ohio Health Group PPO Differential	$3,446.02
Rate for Payer: Ohio Health Group PPO No Differential	$3,747.54
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,972.19
Rate for Payer: PHCS Commercial	$4,135.22
Rate for Payer: United Healthcare All Payer	$3,790.62

Know your out-of-pocket cost for care.

All Charges