Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

HALO HANDS

Professional

Both

$525.00

Hospital Charge Code	22200232
Hospital Revenue Code	222
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$367.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Multiplan PHCS	$315.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$367.50
Rate for Payer: UHCCP Medicaid	$183.75

Halo Hands - PP #1 50%

Professional

Both

$670.00

Hospital Charge Code	22200233
Hospital Revenue Code	222
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$469.00
Rate for Payer: Cash Price	$335.00
Rate for Payer: Multiplan PHCS	$402.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$469.00
Rate for Payer: UHCCP Medicaid	$234.50

Halo Hands - PP #2/3 25%

Professional

Both

$334.00

Hospital Charge Code	22200482
Hospital Revenue Code	222
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$233.80
Rate for Payer: Cash Price	$167.00
Rate for Payer: Multiplan PHCS	$200.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$233.80
Rate for Payer: UHCCP Medicaid	$116.90

HALO NECK

Professional

Both

$525.00

Hospital Charge Code	22200226
Hospital Revenue Code	222
Min. Negotiated Rate	$183.75
Max. Negotiated Rate	$367.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Multiplan PHCS	$315.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$367.50
Rate for Payer: UHCCP Medicaid	$183.75

Halo Neck - PP #1 50%

Professional

Both

$670.00

Hospital Charge Code	22200227
Hospital Revenue Code	222
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$469.00
Rate for Payer: Cash Price	$335.00
Rate for Payer: Multiplan PHCS	$402.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$469.00
Rate for Payer: UHCCP Medicaid	$234.50

Halo Neck - PP #2/3 25%

Professional

Both

$334.00

Hospital Charge Code	22200479
Hospital Revenue Code	222
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$233.80
Rate for Payer: Cash Price	$167.00
Rate for Payer: Multiplan PHCS	$200.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$233.80
Rate for Payer: UHCCP Medicaid	$116.90

HALO PARTIAL FACE - 3 AREAS

Professional

Both

$780.00

Hospital Charge Code	22200234
Hospital Revenue Code	222
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$546.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Multiplan PHCS	$468.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$546.00
Rate for Payer: UHCCP Medicaid	$273.00

HALO PARTIAL FACE - 4 AREAS

Professional

Both

$1,040.00

Hospital Charge Code	22200236
Hospital Revenue Code	222
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$728.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Multiplan PHCS	$624.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$728.00
Rate for Payer: UHCCP Medicaid	$364.00

Halo Partl Face-3Area-PP#1 50%

Professional

Both

$995.00

Hospital Charge Code	22200235
Hospital Revenue Code	222
Min. Negotiated Rate	$348.25
Max. Negotiated Rate	$696.50
Rate for Payer: Cash Price	$497.50
Rate for Payer: Multiplan PHCS	$597.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$696.50
Rate for Payer: UHCCP Medicaid	$348.25

Halo Partl Face-4Area-PP#1 50%

Professional

Both

$1,326.00

Hospital Charge Code	22200237
Hospital Revenue Code	222
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$928.20
Rate for Payer: Cash Price	$663.00
Rate for Payer: Multiplan PHCS	$795.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$928.20
Rate for Payer: UHCCP Medicaid	$464.10

Halo Partl Face4AreaPP#2/3 25%

Professional

Both

$663.00

Hospital Charge Code	22200485
Hospital Revenue Code	222
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$464.10
Rate for Payer: Cash Price	$331.50
Rate for Payer: Multiplan PHCS	$397.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$464.10
Rate for Payer: UHCCP Medicaid	$232.05

Halo Partl Fce-3AreaPP#2/3 25%

Professional

Both

$497.00

Hospital Charge Code	22200484
Hospital Revenue Code	222
Min. Negotiated Rate	$173.95
Max. Negotiated Rate	$347.90
Rate for Payer: Cash Price	$248.50
Rate for Payer: Multiplan PHCS	$298.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$347.90
Rate for Payer: UHCCP Medicaid	$173.95

HALOPERIDOL 5MG SDV

Facility

$63.88

Service Code	HCPCS J1630
Hospital Charge Code	25002122
Hospital Revenue Code	636
Min. Negotiated Rate	$19.16
Max. Negotiated Rate	$61.32
Rate for Payer: Aetna Commercial	$49.19
Rate for Payer: Anthem Medicaid	$21.97
Rate for Payer: Anthem POS/PPO/Traditional	$49.83
Rate for Payer: Cash Price	$31.94
Rate for Payer: Cigna Commercial	$53.02
Rate for Payer: First Health Commercial	$60.69
Rate for Payer: Humana Commercial	$54.30
Rate for Payer: Humana KY Medicaid	$21.97
Rate for Payer: Kentucky WC Medicaid	$22.19
Rate for Payer: Medical Mutual Of Ohio HMO	$52.38
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$47.14
Rate for Payer: Molina Healthcare Benefit Exchange	$19.16
Rate for Payer: Molina Healthcare Medicaid	$22.41
Rate for Payer: Ohio Health Choice Commercial	$56.21
Rate for Payer: Ohio Health Group HMO	$47.91
Rate for Payer: Ohio Health Group PPO Differential	$51.10
Rate for Payer: Ohio Health Group PPO No Differential	$55.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$44.08
Rate for Payer: PHCS Commercial	$61.32
Rate for Payer: United Healthcare All Payer	$56.21

HALOPERIDOL 5MG SDV

Facility

$63.88

Service Code	HCPCS J1630
Hospital Charge Code	25002122
Hospital Revenue Code	636
Min. Negotiated Rate	$19.16
Max. Negotiated Rate	$61.32
Rate for Payer: Aetna Commercial	$49.19
Rate for Payer: Anthem POS/PPO/Traditional	$49.83
Rate for Payer: Cash Price	$31.94
Rate for Payer: Cigna Commercial	$53.02
Rate for Payer: First Health Commercial	$60.69
Rate for Payer: Humana Commercial	$54.30
Rate for Payer: Medical Mutual Of Ohio HMO	$52.38
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$47.14
Rate for Payer: Molina Healthcare Benefit Exchange	$19.16
Rate for Payer: Ohio Health Choice Commercial	$56.21
Rate for Payer: Ohio Health Group HMO	$47.91
Rate for Payer: Ohio Health Group PPO Differential	$51.10
Rate for Payer: Ohio Health Group PPO No Differential	$55.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$44.08
Rate for Payer: PHCS Commercial	$61.32
Rate for Payer: United Healthcare All Payer	$56.21

HALOPERIDOL DECANOATE INJ 50mg

Facility

$320.48

Service Code	HCPCS J1631
Hospital Charge Code	636T0205
Hospital Revenue Code	636
Min. Negotiated Rate	$96.14
Max. Negotiated Rate	$307.66
Rate for Payer: Aetna Commercial	$246.77
Rate for Payer: Anthem Medicaid	$110.21
Rate for Payer: Anthem POS/PPO/Traditional	$249.97
Rate for Payer: Cash Price	$160.24
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: First Health Commercial	$304.46
Rate for Payer: Humana Commercial	$272.41
Rate for Payer: Humana KY Medicaid	$110.21
Rate for Payer: Kentucky WC Medicaid	$111.33
Rate for Payer: Medical Mutual Of Ohio HMO	$262.79
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$236.51
Rate for Payer: Molina Healthcare Benefit Exchange	$96.14
Rate for Payer: Molina Healthcare Medicaid	$112.42
Rate for Payer: Ohio Health Choice Commercial	$282.02
Rate for Payer: Ohio Health Group HMO	$240.36
Rate for Payer: Ohio Health Group PPO Differential	$256.38
Rate for Payer: Ohio Health Group PPO No Differential	$278.82
Rate for Payer: Ohio Health Group PPO SOMC Employees	$221.13
Rate for Payer: PHCS Commercial	$307.66
Rate for Payer: United Healthcare All Payer	$282.02

HALOPERIDOL DECANOATE INJ 50mg

Facility

$320.48

Service Code	HCPCS J1631
Hospital Charge Code	636T0205
Hospital Revenue Code	636
Min. Negotiated Rate	$96.14
Max. Negotiated Rate	$307.66
Rate for Payer: Aetna Commercial	$246.77
Rate for Payer: Anthem POS/PPO/Traditional	$249.97
Rate for Payer: Cash Price	$160.24
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: First Health Commercial	$304.46
Rate for Payer: Humana Commercial	$272.41
Rate for Payer: Medical Mutual Of Ohio HMO	$262.79
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$236.51
Rate for Payer: Molina Healthcare Benefit Exchange	$96.14
Rate for Payer: Ohio Health Choice Commercial	$282.02
Rate for Payer: Ohio Health Group HMO	$240.36
Rate for Payer: Ohio Health Group PPO Differential	$256.38
Rate for Payer: Ohio Health Group PPO No Differential	$278.82
Rate for Payer: Ohio Health Group PPO SOMC Employees	$221.13
Rate for Payer: PHCS Commercial	$307.66
Rate for Payer: United Healthcare All Payer	$282.02

HALOPERIDOL DECANOATE INJ 50mg

Facility

$320.48

Service Code	HCPCS J1631
Hospital Charge Code	63600205
Hospital Revenue Code	636
Min. Negotiated Rate	$96.14
Max. Negotiated Rate	$307.66
Rate for Payer: Aetna Commercial	$246.77
Rate for Payer: Anthem Medicaid	$110.21
Rate for Payer: Anthem POS/PPO/Traditional	$249.97
Rate for Payer: Cash Price	$160.24
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: First Health Commercial	$304.46
Rate for Payer: Humana Commercial	$272.41
Rate for Payer: Humana KY Medicaid	$110.21
Rate for Payer: Kentucky WC Medicaid	$111.33
Rate for Payer: Medical Mutual Of Ohio HMO	$262.79
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$236.51
Rate for Payer: Molina Healthcare Benefit Exchange	$96.14
Rate for Payer: Molina Healthcare Medicaid	$112.42
Rate for Payer: Ohio Health Choice Commercial	$282.02
Rate for Payer: Ohio Health Group HMO	$240.36
Rate for Payer: Ohio Health Group PPO Differential	$256.38
Rate for Payer: Ohio Health Group PPO No Differential	$278.82
Rate for Payer: Ohio Health Group PPO SOMC Employees	$221.13
Rate for Payer: PHCS Commercial	$307.66
Rate for Payer: United Healthcare All Payer	$282.02

HALOPERIDOL DECANOATE INJ 50mg

Professional

Both

$320.48

Service Code	HCPCS J1631
Hospital Charge Code	63600205
Hospital Revenue Code	636
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$192.29
Rate for Payer: Aetna Commercial	$13.09
Rate for Payer: Ambetter Exchange	$4.68
Rate for Payer: Buckeye Individual/Medicaid	$4.68
Rate for Payer: Buckeye Medicare Advantage	$4.68
Rate for Payer: CareSource Just4Me Medicare	$5.62
Rate for Payer: Cash Price	$160.24
Rate for Payer: Cash Price	$160.24
Rate for Payer: Healthspan PPO	$8.77
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$18.85
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$4.68
Rate for Payer: Molina Healthcare Benefit Exchange	$4.68
Rate for Payer: Multiplan PHCS	$192.29
Rate for Payer: Ohio Health Choice Preferred Health Choice	$6.08
Rate for Payer: UHCCP Medicaid	$112.17
Rate for Payer: Wellcare Medicare Advantage	$4.68

HALOPERIDOL DECANOATE INJ 50mg

Facility

$320.48

Service Code	HCPCS J1631
Hospital Charge Code	63600205
Hospital Revenue Code	636
Min. Negotiated Rate	$96.14
Max. Negotiated Rate	$307.66
Rate for Payer: Aetna Commercial	$246.77
Rate for Payer: Anthem POS/PPO/Traditional	$249.97
Rate for Payer: Cash Price	$160.24
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: First Health Commercial	$304.46
Rate for Payer: Humana Commercial	$272.41
Rate for Payer: Medical Mutual Of Ohio HMO	$262.79
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$236.51
Rate for Payer: Molina Healthcare Benefit Exchange	$96.14
Rate for Payer: Ohio Health Choice Commercial	$282.02
Rate for Payer: Ohio Health Group HMO	$240.36
Rate for Payer: Ohio Health Group PPO Differential	$256.38
Rate for Payer: Ohio Health Group PPO No Differential	$278.82
Rate for Payer: Ohio Health Group PPO SOMC Employees	$221.13
Rate for Payer: PHCS Commercial	$307.66
Rate for Payer: United Healthcare All Payer	$282.02

HA METATARSOPHALANGEAL JT

Facility

$1,188.00

Service Code	HCPCS 28899
Hospital Charge Code	76102929
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$1,140.48
Rate for Payer: Aetna Commercial	$914.76
Rate for Payer: Anthem Medicaid	$408.55
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$926.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$986.04
Rate for Payer: First Health Commercial	$1,128.60
Rate for Payer: Humana Commercial	$1,009.80
Rate for Payer: Humana KY Medicaid	$408.55
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$412.71
Rate for Payer: Medical Mutual Of Ohio HMO	$974.16
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$876.74
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$416.75
Rate for Payer: Ohio Health Choice Commercial	$1,045.44
Rate for Payer: Ohio Health Group HMO	$891.00
Rate for Payer: Ohio Health Group PPO Differential	$950.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,033.56
Rate for Payer: Ohio Health Group PPO SOMC Employees	$819.72
Rate for Payer: PHCS Commercial	$1,140.48
Rate for Payer: United Healthcare All Payer	$1,045.44

HA METATARSOPHALANGEAL JT

Professional

Both

$1,188.00

Service Code	HCPCS 28899
Hospital Charge Code	76102929
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$831.60
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Multiplan PHCS	$712.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$831.60
Rate for Payer: UHCCP Medicaid	$415.80

HA METATARSOPHALANGEAL JT

Facility

$1,188.00

Service Code	HCPCS 28899
Hospital Charge Code	76102929
Hospital Revenue Code	761
Min. Negotiated Rate	$356.40
Max. Negotiated Rate	$1,140.48
Rate for Payer: Aetna Commercial	$914.76
Rate for Payer: Anthem POS/PPO/Traditional	$926.64
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$986.04
Rate for Payer: First Health Commercial	$1,128.60
Rate for Payer: Humana Commercial	$1,009.80
Rate for Payer: Medical Mutual Of Ohio HMO	$974.16
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$876.74
Rate for Payer: Molina Healthcare Benefit Exchange	$356.40
Rate for Payer: Ohio Health Choice Commercial	$1,045.44
Rate for Payer: Ohio Health Group HMO	$891.00
Rate for Payer: Ohio Health Group PPO Differential	$950.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,033.56
Rate for Payer: Ohio Health Group PPO SOMC Employees	$819.72
Rate for Payer: PHCS Commercial	$1,140.48
Rate for Payer: United Healthcare All Payer	$1,045.44

HAND 2 VIEW

Professional

Both

$404.00

Service Code	HCPCS 73120
Hospital Charge Code	32000087
Hospital Revenue Code	320
Min. Negotiated Rate	$10.38
Max. Negotiated Rate	$242.40
Rate for Payer: Aetna Commercial	$40.28
Rate for Payer: Ambetter Exchange	$28.24
Rate for Payer: Anthem Medicaid	$20.15
Rate for Payer: Buckeye Individual/Medicaid	$28.24
Rate for Payer: Buckeye Medicare Advantage	$28.24
Rate for Payer: CareSource Just4Me Medicare	$33.89
Rate for Payer: Cash Price	$202.00
Rate for Payer: Cash Price	$202.00
Rate for Payer: Cigna Commercial	$39.75
Rate for Payer: Healthspan PPO	$37.74
Rate for Payer: Humana Medicaid	$20.15
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$10.38
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$28.24
Rate for Payer: Molina Healthcare Benefit Exchange	$28.24
Rate for Payer: Molina Healthcare CHIP/Medicaid	$20.55
Rate for Payer: Molina Healthcare Passport	$20.15
Rate for Payer: Multiplan PHCS	$242.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$36.71
Rate for Payer: UHCCP Medicaid	$141.40
Rate for Payer: Wellcare CHIP/Medicaid	$20.35
Rate for Payer: Wellcare Medicare Advantage	$28.24

HAND 2 VIEW

Facility

$404.00

Service Code	HCPCS 73120
Hospital Charge Code	32000087
Hospital Revenue Code	320
Min. Negotiated Rate	$98.26
Max. Negotiated Rate	$387.84
Rate for Payer: Aetna Commercial	$311.08
Rate for Payer: Anthem Medicaid	$138.94
Rate for Payer: Anthem Medicare Advantage/PPO	$98.26
Rate for Payer: Anthem POS/PPO/Traditional	$315.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$137.56
Rate for Payer: CareSource Just4Me Medicare	$132.65
Rate for Payer: Cash Price	$202.00
Rate for Payer: Cash Price	$202.00
Rate for Payer: Cigna Commercial	$335.32
Rate for Payer: First Health Commercial	$383.80
Rate for Payer: Humana Commercial	$343.40
Rate for Payer: Humana KY Medicaid	$138.94
Rate for Payer: Humana Medicare Advantage	$98.26
Rate for Payer: Kentucky WC Medicaid	$140.35
Rate for Payer: Medical Mutual Of Ohio HMO	$331.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$298.15
Rate for Payer: Molina Healthcare Benefit Exchange	$117.91
Rate for Payer: Molina Healthcare Medicaid	$141.72
Rate for Payer: Ohio Health Choice Commercial	$355.52
Rate for Payer: Ohio Health Group HMO	$303.00
Rate for Payer: Ohio Health Group PPO Differential	$323.20
Rate for Payer: Ohio Health Group PPO No Differential	$351.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$278.76
Rate for Payer: PHCS Commercial	$387.84
Rate for Payer: United Healthcare All Payer	$355.52

HAND 2 VIEW

Facility

$404.00

Service Code	HCPCS 73120
Hospital Charge Code	32000087
Hospital Revenue Code	320
Min. Negotiated Rate	$121.20
Max. Negotiated Rate	$387.84
Rate for Payer: Aetna Commercial	$311.08
Rate for Payer: Anthem POS/PPO/Traditional	$315.12
Rate for Payer: Cash Price	$202.00
Rate for Payer: Cigna Commercial	$335.32
Rate for Payer: First Health Commercial	$383.80
Rate for Payer: Humana Commercial	$343.40
Rate for Payer: Medical Mutual Of Ohio HMO	$331.28
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$298.15
Rate for Payer: Molina Healthcare Benefit Exchange	$121.20
Rate for Payer: Ohio Health Choice Commercial	$355.52
Rate for Payer: Ohio Health Group HMO	$303.00
Rate for Payer: Ohio Health Group PPO Differential	$323.20
Rate for Payer: Ohio Health Group PPO No Differential	$351.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$278.76
Rate for Payer: PHCS Commercial	$387.84
Rate for Payer: United Healthcare All Payer	$355.52

Know your out-of-pocket cost for care.

All Charges