Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

FY Face,Chest - PP #1 50%

Professional

Both

$734.00

Hospital Charge Code	22200263
Hospital Revenue Code	222
Min. Negotiated Rate	$256.90
Max. Negotiated Rate	$513.80
Rate for Payer: Cash Price	$367.00
Rate for Payer: Multiplan PHCS	$440.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$513.80
Rate for Payer: UHCCP Medicaid	$256.90

FY Face,Chest -PP#2/3 25%

Professional

Both

$366.00

Hospital Charge Code	22200681
Hospital Revenue Code	222
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$256.20
Rate for Payer: Cash Price	$183.00
Rate for Payer: Multiplan PHCS	$219.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$256.20
Rate for Payer: UHCCP Medicaid	$128.10

FY Face, Neck and Chest

Professional

Both

$750.00

Hospital Charge Code	22200680
Hospital Revenue Code	222
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$525.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Multiplan PHCS	$450.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$525.00
Rate for Payer: UHCCP Medicaid	$262.50

FY Face, Neck,Chest -PP #1 50%

Professional

Both

$956.00

Hospital Charge Code	22200264
Hospital Revenue Code	222
Min. Negotiated Rate	$334.60
Max. Negotiated Rate	$669.20
Rate for Payer: Cash Price	$478.00
Rate for Payer: Multiplan PHCS	$573.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$669.20
Rate for Payer: UHCCP Medicaid	$334.60

FY Face, Neck,Chest-PP#2/3 25%

Professional

Both

$478.00

Hospital Charge Code	22200679
Hospital Revenue Code	222
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$334.60
Rate for Payer: Cash Price	$239.00
Rate for Payer: Multiplan PHCS	$286.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$334.60
Rate for Payer: UHCCP Medicaid	$167.30

FY Full Face

Professional

Both

$375.00

Hospital Charge Code	22200686
Hospital Revenue Code	222
Min. Negotiated Rate	$131.25
Max. Negotiated Rate	$262.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Multiplan PHCS	$225.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$262.50
Rate for Payer: UHCCP Medicaid	$131.25

FY Full Face - PP #1 50%

Professional

Both

$478.00

Hospital Charge Code	22200261
Hospital Revenue Code	222
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$334.60
Rate for Payer: Cash Price	$239.00
Rate for Payer: Multiplan PHCS	$286.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$334.60
Rate for Payer: UHCCP Medicaid	$167.30

FY Full Face - PP #2/3 25%

Professional

Both

$239.00

Hospital Charge Code	22200685
Hospital Revenue Code	222
Min. Negotiated Rate	$83.65
Max. Negotiated Rate	$167.30
Rate for Payer: Cash Price	$119.50
Rate for Payer: Multiplan PHCS	$143.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$167.30
Rate for Payer: UHCCP Medicaid	$83.65

FY Neck or Chest

Professional

Both

$200.00

Hospital Charge Code	22200684
Hospital Revenue Code	222
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Multiplan PHCS	$120.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$140.00
Rate for Payer: UHCCP Medicaid	$70.00

FY Neck or Chest - PP #1 50%

Professional

Both

$256.00

Hospital Charge Code	22200262
Hospital Revenue Code	222
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$179.20
Rate for Payer: Cash Price	$128.00
Rate for Payer: Multiplan PHCS	$153.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$179.20
Rate for Payer: UHCCP Medicaid	$89.60

FY Neck or Chest-PP#2/3 25%

Professional

Both

$127.00

Hospital Charge Code	22200683
Hospital Revenue Code	222
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$88.90
Rate for Payer: Cash Price	$63.50
Rate for Payer: Multiplan PHCS	$76.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$88.90
Rate for Payer: UHCCP Medicaid	$44.45

FY Upper Legs

Professional

Both

$1,100.00

Hospital Charge Code	22200711
Hospital Revenue Code	222
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$770.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$770.00
Rate for Payer: UHCCP Medicaid	$385.00

FY Upper Legs - PP #1 50%

Professional

Both

$1,402.50

Hospital Charge Code	22200712
Hospital Revenue Code	222
Min. Negotiated Rate	$490.88
Max. Negotiated Rate	$981.75
Rate for Payer: Cash Price	$701.25
Rate for Payer: Multiplan PHCS	$841.50
Rate for Payer: Ohio Health Choice Preferred Health Choice	$981.75
Rate for Payer: UHCCP Medicaid	$490.88

FY Upper Legs-PP#2/3 25%

Professional

Both

$701.25

Hospital Charge Code	22200713
Hospital Revenue Code	222
Min. Negotiated Rate	$245.44
Max. Negotiated Rate	$490.88
Rate for Payer: Cash Price	$350.62
Rate for Payer: Multiplan PHCS	$420.75
Rate for Payer: Ohio Health Choice Preferred Health Choice	$490.88
Rate for Payer: UHCCP Medicaid	$245.44

G2 CONST INSERT SZ 1-2 11MM

Facility

$13,996.20

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,198.86
Max. Negotiated Rate	$13,436.35
Rate for Payer: Aetna Commercial	$10,777.07
Rate for Payer: Anthem POS/PPO/Traditional	$10,917.04
Rate for Payer: Cash Price	$6,998.10
Rate for Payer: Cigna Commercial	$11,616.85
Rate for Payer: First Health Commercial	$13,296.39
Rate for Payer: Humana Commercial	$11,896.77
Rate for Payer: Medical Mutual Of Ohio HMO	$11,476.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$10,329.20
Rate for Payer: Molina Healthcare Benefit Exchange	$4,198.86
Rate for Payer: Ohio Health Choice Commercial	$12,316.66
Rate for Payer: Ohio Health Group HMO	$10,497.15
Rate for Payer: Ohio Health Group PPO Differential	$11,196.96
Rate for Payer: Ohio Health Group PPO No Differential	$12,176.69
Rate for Payer: Ohio Health Group PPO SOMC Employees	$9,657.38
Rate for Payer: PHCS Commercial	$13,436.35
Rate for Payer: United Healthcare All Payer	$12,316.66

G2 CONST INSERT SZ 1-2 11MM

Facility

$13,996.20

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,198.86
Max. Negotiated Rate	$13,436.35
Rate for Payer: Aetna Commercial	$10,777.07
Rate for Payer: Anthem Medicaid	$4,813.29
Rate for Payer: Anthem POS/PPO/Traditional	$10,917.04
Rate for Payer: Cash Price	$6,998.10
Rate for Payer: Cigna Commercial	$11,616.85
Rate for Payer: First Health Commercial	$13,296.39
Rate for Payer: Humana Commercial	$11,896.77
Rate for Payer: Humana KY Medicaid	$4,813.29
Rate for Payer: Kentucky WC Medicaid	$4,862.28
Rate for Payer: Medical Mutual Of Ohio HMO	$11,476.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$10,329.20
Rate for Payer: Molina Healthcare Benefit Exchange	$4,198.86
Rate for Payer: Molina Healthcare Medicaid	$4,909.87
Rate for Payer: Ohio Health Choice Commercial	$12,316.66
Rate for Payer: Ohio Health Group HMO	$10,497.15
Rate for Payer: Ohio Health Group PPO Differential	$11,196.96
Rate for Payer: Ohio Health Group PPO No Differential	$12,176.69
Rate for Payer: Ohio Health Group PPO SOMC Employees	$9,657.38
Rate for Payer: PHCS Commercial	$13,436.35
Rate for Payer: United Healthcare All Payer	$12,316.66

G2 CONST INSERT SZ 1-2 13MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 13MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem Medicaid	$5,464.06
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Humana KY Medicaid	$5,464.06
Rate for Payer: Kentucky WC Medicaid	$5,519.66
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Molina Healthcare Medicaid	$5,573.69
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 15MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 15MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem Medicaid	$5,464.06
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Humana KY Medicaid	$5,464.06
Rate for Payer: Kentucky WC Medicaid	$5,519.66
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Molina Healthcare Medicaid	$5,573.69
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 18MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 18MM

Facility

$15,888.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$15,252.96
Rate for Payer: Aetna Commercial	$12,234.15
Rate for Payer: Anthem Medicaid	$5,464.06
Rate for Payer: Anthem POS/PPO/Traditional	$12,393.03
Rate for Payer: Cash Price	$7,944.25
Rate for Payer: Cigna Commercial	$13,187.45
Rate for Payer: First Health Commercial	$15,094.08
Rate for Payer: Humana Commercial	$13,505.23
Rate for Payer: Humana KY Medicaid	$5,464.06
Rate for Payer: Kentucky WC Medicaid	$5,519.66
Rate for Payer: Medical Mutual Of Ohio HMO	$13,028.57
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,725.71
Rate for Payer: Molina Healthcare Benefit Exchange	$4,766.55
Rate for Payer: Molina Healthcare Medicaid	$5,573.69
Rate for Payer: Ohio Health Choice Commercial	$13,981.88
Rate for Payer: Ohio Health Group HMO	$11,916.38
Rate for Payer: Ohio Health Group PPO Differential	$12,710.80
Rate for Payer: Ohio Health Group PPO No Differential	$13,823.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,963.07
Rate for Payer: PHCS Commercial	$15,252.96
Rate for Payer: United Healthcare All Payer	$13,981.88

G2 CONST INSERT SZ 1-2 21MM

Facility

$10,070.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$3,021.18
Max. Negotiated Rate	$9,667.78
Rate for Payer: Aetna Commercial	$7,754.36
Rate for Payer: Anthem POS/PPO/Traditional	$7,855.07
Rate for Payer: Cash Price	$5,035.30
Rate for Payer: Cigna Commercial	$8,358.60
Rate for Payer: First Health Commercial	$9,567.07
Rate for Payer: Humana Commercial	$8,560.01
Rate for Payer: Medical Mutual Of Ohio HMO	$8,257.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,432.10
Rate for Payer: Molina Healthcare Benefit Exchange	$3,021.18
Rate for Payer: Ohio Health Choice Commercial	$8,862.13
Rate for Payer: Ohio Health Group HMO	$7,552.95
Rate for Payer: Ohio Health Group PPO Differential	$8,056.48
Rate for Payer: Ohio Health Group PPO No Differential	$8,761.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,948.71
Rate for Payer: PHCS Commercial	$9,667.78
Rate for Payer: United Healthcare All Payer	$8,862.13

G2 CONST INSERT SZ 1-2 21MM

Facility

$10,070.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$3,021.18
Max. Negotiated Rate	$9,667.78
Rate for Payer: Aetna Commercial	$7,754.36
Rate for Payer: Anthem Medicaid	$3,463.28
Rate for Payer: Anthem POS/PPO/Traditional	$7,855.07
Rate for Payer: Cash Price	$5,035.30
Rate for Payer: Cigna Commercial	$8,358.60
Rate for Payer: First Health Commercial	$9,567.07
Rate for Payer: Humana Commercial	$8,560.01
Rate for Payer: Humana KY Medicaid	$3,463.28
Rate for Payer: Kentucky WC Medicaid	$3,498.53
Rate for Payer: Medical Mutual Of Ohio HMO	$8,257.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,432.10
Rate for Payer: Molina Healthcare Benefit Exchange	$3,021.18
Rate for Payer: Molina Healthcare Medicaid	$3,532.77
Rate for Payer: Ohio Health Choice Commercial	$8,862.13
Rate for Payer: Ohio Health Group HMO	$7,552.95
Rate for Payer: Ohio Health Group PPO Differential	$8,056.48
Rate for Payer: Ohio Health Group PPO No Differential	$8,761.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,948.71
Rate for Payer: PHCS Commercial	$9,667.78
Rate for Payer: United Healthcare All Payer	$8,862.13

G2 CONST INSERT SZ 1-2 25MM

Facility

$10,070.60

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$3,021.18
Max. Negotiated Rate	$9,667.78
Rate for Payer: Aetna Commercial	$7,754.36
Rate for Payer: Anthem Medicaid	$3,463.28
Rate for Payer: Anthem POS/PPO/Traditional	$7,855.07
Rate for Payer: Cash Price	$5,035.30
Rate for Payer: Cigna Commercial	$8,358.60
Rate for Payer: First Health Commercial	$9,567.07
Rate for Payer: Humana Commercial	$8,560.01
Rate for Payer: Humana KY Medicaid	$3,463.28
Rate for Payer: Kentucky WC Medicaid	$3,498.53
Rate for Payer: Medical Mutual Of Ohio HMO	$8,257.89
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$7,432.10
Rate for Payer: Molina Healthcare Benefit Exchange	$3,021.18
Rate for Payer: Molina Healthcare Medicaid	$3,532.77
Rate for Payer: Ohio Health Choice Commercial	$8,862.13
Rate for Payer: Ohio Health Group HMO	$7,552.95
Rate for Payer: Ohio Health Group PPO Differential	$8,056.48
Rate for Payer: Ohio Health Group PPO No Differential	$8,761.42
Rate for Payer: Ohio Health Group PPO SOMC Employees	$6,948.71
Rate for Payer: PHCS Commercial	$9,667.78
Rate for Payer: United Healthcare All Payer	$8,862.13

Know your out-of-pocket cost for care.

All Charges