Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

MONTAGE PUL GEN FULL BDY MRI S

Facility

$91,440.00

Service Code	HCPCS C1820
Hospital Charge Code	27000082
Hospital Revenue Code	278
Min. Negotiated Rate	$27,432.00
Max. Negotiated Rate	$87,782.40
Rate for Payer: Aetna Commercial	$70,408.80
Rate for Payer: Anthem POS/PPO/Traditional	$71,323.20
Rate for Payer: Cash Price	$45,720.00
Rate for Payer: Cigna Commercial	$75,895.20
Rate for Payer: First Health Commercial	$86,868.00
Rate for Payer: Humana Commercial	$77,724.00
Rate for Payer: Medical Mutual Of Ohio HMO	$74,980.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$67,482.72
Rate for Payer: Molina Healthcare Benefit Exchange	$27,432.00
Rate for Payer: Ohio Health Choice Commercial	$80,467.20
Rate for Payer: Ohio Health Group HMO	$68,580.00
Rate for Payer: Ohio Health Group PPO Differential	$73,152.00
Rate for Payer: Ohio Health Group PPO No Differential	$79,552.80
Rate for Payer: Ohio Health Group PPO SOMC Employees	$63,093.60
Rate for Payer: PHCS Commercial	$87,782.40
Rate for Payer: United Healthcare All Payer	$80,467.20

MONTR CARDI CONFIRM ICM DM2100

Facility

$15,500.00

Service Code	HCPCS C1764
Hospital Charge Code	27000049
Hospital Revenue Code	275
Min. Negotiated Rate	$4,650.00
Max. Negotiated Rate	$14,880.00
Rate for Payer: Aetna Commercial	$11,935.00
Rate for Payer: Anthem Medicaid	$5,330.45
Rate for Payer: Anthem POS/PPO/Traditional	$12,090.00
Rate for Payer: Cash Price	$7,750.00
Rate for Payer: Cigna Commercial	$12,865.00
Rate for Payer: First Health Commercial	$14,725.00
Rate for Payer: Humana Commercial	$13,175.00
Rate for Payer: Humana KY Medicaid	$5,330.45
Rate for Payer: Kentucky WC Medicaid	$5,384.70
Rate for Payer: Medical Mutual Of Ohio HMO	$12,710.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,439.00
Rate for Payer: Molina Healthcare Benefit Exchange	$4,650.00
Rate for Payer: Molina Healthcare Medicaid	$5,437.40
Rate for Payer: Ohio Health Choice Commercial	$13,640.00
Rate for Payer: Ohio Health Group HMO	$11,625.00
Rate for Payer: Ohio Health Group PPO Differential	$12,400.00
Rate for Payer: Ohio Health Group PPO No Differential	$13,485.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,695.00
Rate for Payer: PHCS Commercial	$14,880.00
Rate for Payer: United Healthcare All Payer	$13,640.00

MONTR CARDI CONFIRM ICM DM2100

Facility

$15,500.00

Service Code	HCPCS C1764
Hospital Charge Code	27000049
Hospital Revenue Code	275
Min. Negotiated Rate	$4,650.00
Max. Negotiated Rate	$14,880.00
Rate for Payer: Aetna Commercial	$11,935.00
Rate for Payer: Anthem POS/PPO/Traditional	$12,090.00
Rate for Payer: Cash Price	$7,750.00
Rate for Payer: Cigna Commercial	$12,865.00
Rate for Payer: First Health Commercial	$14,725.00
Rate for Payer: Humana Commercial	$13,175.00
Rate for Payer: Medical Mutual Of Ohio HMO	$12,710.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,439.00
Rate for Payer: Molina Healthcare Benefit Exchange	$4,650.00
Rate for Payer: Ohio Health Choice Commercial	$13,640.00
Rate for Payer: Ohio Health Group HMO	$11,625.00
Rate for Payer: Ohio Health Group PPO Differential	$12,400.00
Rate for Payer: Ohio Health Group PPO No Differential	$13,485.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,695.00
Rate for Payer: PHCS Commercial	$14,880.00
Rate for Payer: United Healthcare All Payer	$13,640.00

MONUROL 3 GRAM PACKET

Facility

$132.00

Service Code	NDC 69097057967
Hospital Charge Code	25003219
Hospital Revenue Code	250
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$126.72
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Anthem Medicaid	$45.39
Rate for Payer: Anthem POS/PPO/Traditional	$102.96
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cigna Commercial	$109.56
Rate for Payer: First Health Commercial	$125.40
Rate for Payer: Humana Commercial	$112.20
Rate for Payer: Humana KY Medicaid	$45.39
Rate for Payer: Kentucky WC Medicaid	$45.86
Rate for Payer: Medical Mutual Of Ohio HMO	$108.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$97.42
Rate for Payer: Molina Healthcare Benefit Exchange	$39.60
Rate for Payer: Molina Healthcare Medicaid	$46.31
Rate for Payer: Ohio Health Choice Commercial	$116.16
Rate for Payer: Ohio Health Group HMO	$99.00
Rate for Payer: Ohio Health Group PPO Differential	$105.60
Rate for Payer: Ohio Health Group PPO No Differential	$114.84
Rate for Payer: Ohio Health Group PPO SOMC Employees	$91.08
Rate for Payer: PHCS Commercial	$126.72
Rate for Payer: United Healthcare All Payer	$116.16

MONUROL 3 GRAM PACKET

Facility

$132.00

Service Code	NDC 69097057967
Hospital Charge Code	25003219
Hospital Revenue Code	250
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$126.72
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Anthem POS/PPO/Traditional	$102.96
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cigna Commercial	$109.56
Rate for Payer: First Health Commercial	$125.40
Rate for Payer: Humana Commercial	$112.20
Rate for Payer: Medical Mutual Of Ohio HMO	$108.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$97.42
Rate for Payer: Molina Healthcare Benefit Exchange	$39.60
Rate for Payer: Ohio Health Choice Commercial	$116.16
Rate for Payer: Ohio Health Group HMO	$99.00
Rate for Payer: Ohio Health Group PPO Differential	$105.60
Rate for Payer: Ohio Health Group PPO No Differential	$114.84
Rate for Payer: Ohio Health Group PPO SOMC Employees	$91.08
Rate for Payer: PHCS Commercial	$126.72
Rate for Payer: United Healthcare All Payer	$116.16

MORPHEUS8-ACNESCARMARKPP#1 50%

Professional

Both

$1,148.00

Hospital Charge Code	22200736
Hospital Revenue Code	222
Min. Negotiated Rate	$401.80
Max. Negotiated Rate	$803.60
Rate for Payer: Cash Price	$574.00
Rate for Payer: Multiplan PHCS	$688.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$803.60
Rate for Payer: UHCCP Medicaid	$401.80

MORPHEUS8ACNESCARMARKPP2/3 25%

Professional

Both

$574.00

Hospital Charge Code	22200737
Hospital Revenue Code	222
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$401.80
Rate for Payer: Cash Price	$287.00
Rate for Payer: Multiplan PHCS	$344.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$401.80
Rate for Payer: UHCCP Medicaid	$200.90

MORPHEUS8-ACNE/SCARS/MARKS

Professional

Both

$900.00

Hospital Charge Code	22200735
Hospital Revenue Code	222
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$630.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Multiplan PHCS	$540.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$630.00
Rate for Payer: UHCCP Medicaid	$315.00

MORPHEUS8-BODYTGHT LG PP#1 50%

Professional

Both

$1,913.00

Hospital Charge Code	22200742
Hospital Revenue Code	222
Min. Negotiated Rate	$669.55
Max. Negotiated Rate	$1,339.10
Rate for Payer: Cash Price	$956.50
Rate for Payer: Multiplan PHCS	$1,147.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,339.10
Rate for Payer: UHCCP Medicaid	$669.55

MORPHEUS8-BODYTGHTLGPP#2/3 25%

Professional

Both

$956.00

Hospital Charge Code	22200743
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

MORPHEUS8-BODYTGHT SM PP#1 50%

Professional

Both

$1,148.00

Hospital Charge Code	22200739
Hospital Revenue Code	222
Min. Negotiated Rate	$401.80
Max. Negotiated Rate	$803.60
Rate for Payer: Cash Price	$574.00
Rate for Payer: Multiplan PHCS	$688.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$803.60
Rate for Payer: UHCCP Medicaid	$401.80

MORPHEUS8-BODYTGHTSMPP#2/3 25%

Professional

Both

$574.00

Hospital Charge Code	22200740
Hospital Revenue Code	222
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$401.80
Rate for Payer: Cash Price	$287.00
Rate for Payer: Multiplan PHCS	$344.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$401.80
Rate for Payer: UHCCP Medicaid	$200.90

MORPHEUS8-BODY TIGHT LG AREA

Professional

Both

$1,500.00

Hospital Charge Code	22200741
Hospital Revenue Code	222
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$1,050.00
Rate for Payer: Cash Price	$750.00
Rate for Payer: Multiplan PHCS	$900.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,050.00
Rate for Payer: UHCCP Medicaid	$525.00

MORPHEUS8-BODY TIGHT SM AREA

Professional

Both

$900.00

Hospital Charge Code	22200738
Hospital Revenue Code	222
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$630.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Multiplan PHCS	$540.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$630.00
Rate for Payer: UHCCP Medicaid	$315.00

MORPHEUS8-EYES/LIPS/NASO

Professional

Both

$350.00

Hospital Charge Code	22200732
Hospital Revenue Code	222
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$245.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Multiplan PHCS	$210.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$245.00
Rate for Payer: UHCCP Medicaid	$122.50

MORPHEUS8-EYESLIPSNASOPP#1 50%

Professional

Both

$446.00

Hospital Charge Code	22200733
Hospital Revenue Code	222
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$312.20
Rate for Payer: Cash Price	$223.00
Rate for Payer: Multiplan PHCS	$267.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$312.20
Rate for Payer: UHCCP Medicaid	$156.10

MORPHEUS8EYESLIPSNASPP#2/3 25%

Professional

Both

$223.00

Hospital Charge Code	22200734
Hospital Revenue Code	222
Min. Negotiated Rate	$78.05
Max. Negotiated Rate	$156.10
Rate for Payer: Cash Price	$111.50
Rate for Payer: Multiplan PHCS	$133.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$156.10
Rate for Payer: UHCCP Medicaid	$78.05

MORPHEUS8-FACE/NECK

Professional

Both

$900.00

Hospital Charge Code	22200729
Hospital Revenue Code	222
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$630.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Multiplan PHCS	$540.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$630.00
Rate for Payer: UHCCP Medicaid	$315.00

MORPHEUS8-FACE/NECK PP#1 50%

Professional

Both

$1,148.00

Hospital Charge Code	22200730
Hospital Revenue Code	222
Min. Negotiated Rate	$401.80
Max. Negotiated Rate	$803.60
Rate for Payer: Cash Price	$574.00
Rate for Payer: Multiplan PHCS	$688.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$803.60
Rate for Payer: UHCCP Medicaid	$401.80

MORPHEUS8-FACE/NECK PP#2/3 25%

Professional

Both

$574.00

Hospital Charge Code	22200731
Hospital Revenue Code	222
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$401.80
Rate for Payer: Cash Price	$287.00
Rate for Payer: Multiplan PHCS	$344.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$401.80
Rate for Payer: UHCCP Medicaid	$200.90

MORPHEUS8-HYPERHYDRO PP#1 50%

Professional

Both

$854.00

Hospital Charge Code	22200745
Hospital Revenue Code	222
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$597.80
Rate for Payer: Cash Price	$427.00
Rate for Payer: Multiplan PHCS	$512.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$597.80
Rate for Payer: UHCCP Medicaid	$298.90

MORPHEUS8-HYPERHYDROSIS

Professional

Both

$670.00

Hospital Charge Code	22200744
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

MORPHEUS8-HYPERHYDR PP#2/3 25%

Professional

Both

$427.00

Hospital Charge Code	22200746
Hospital Revenue Code	222
Min. Negotiated Rate	$149.45
Max. Negotiated Rate	$298.90
Rate for Payer: Cash Price	$213.50
Rate for Payer: Multiplan PHCS	$256.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$298.90
Rate for Payer: UHCCP Medicaid	$149.45

MORPHINE 0.4MG/ML ORSOL(0.5ML)

Facility

$60.19

Service Code	NDC 27808008202
Hospital Charge Code	25003222
Hospital Revenue Code	250
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$57.78
Rate for Payer: Aetna Commercial	$46.35
Rate for Payer: Anthem POS/PPO/Traditional	$46.95
Rate for Payer: Cash Price	$30.09
Rate for Payer: Cigna Commercial	$49.96
Rate for Payer: First Health Commercial	$57.18
Rate for Payer: Humana Commercial	$51.16
Rate for Payer: Medical Mutual Of Ohio HMO	$49.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$44.42
Rate for Payer: Molina Healthcare Benefit Exchange	$18.06
Rate for Payer: Ohio Health Choice Commercial	$52.97
Rate for Payer: Ohio Health Group HMO	$45.14
Rate for Payer: Ohio Health Group PPO Differential	$48.15
Rate for Payer: Ohio Health Group PPO No Differential	$52.37
Rate for Payer: Ohio Health Group PPO SOMC Employees	$41.53
Rate for Payer: PHCS Commercial	$57.78
Rate for Payer: United Healthcare All Payer	$52.97

MORPHINE 0.4MG/ML ORSOL(0.5ML)

Facility

$60.19

Service Code	NDC 27808008202
Hospital Charge Code	25003222
Hospital Revenue Code	250
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$57.78
Rate for Payer: Aetna Commercial	$46.35
Rate for Payer: Anthem Medicaid	$20.70
Rate for Payer: Anthem POS/PPO/Traditional	$46.95
Rate for Payer: Cash Price	$30.09
Rate for Payer: Cigna Commercial	$49.96
Rate for Payer: First Health Commercial	$57.18
Rate for Payer: Humana Commercial	$51.16
Rate for Payer: Humana KY Medicaid	$20.70
Rate for Payer: Kentucky WC Medicaid	$20.91
Rate for Payer: Medical Mutual Of Ohio HMO	$49.36
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$44.42
Rate for Payer: Molina Healthcare Benefit Exchange	$18.06
Rate for Payer: Molina Healthcare Medicaid	$21.11
Rate for Payer: Ohio Health Choice Commercial	$52.97
Rate for Payer: Ohio Health Group HMO	$45.14
Rate for Payer: Ohio Health Group PPO Differential	$48.15
Rate for Payer: Ohio Health Group PPO No Differential	$52.37
Rate for Payer: Ohio Health Group PPO SOMC Employees	$41.53
Rate for Payer: PHCS Commercial	$57.78
Rate for Payer: United Healthcare All Payer	$52.97

Know your out-of-pocket cost for care.

All Charges