Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

PF FULL FACE

Professional

Both

$2,900.00

Hospital Charge Code	22200307
Hospital Revenue Code	222
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$2,900.00
Rate for Payer: Buckeye Medicare Advantage	$2,900.00
Rate for Payer: Cash Price	$1,450.00
Rate for Payer: Multiplan PHCS	$1,740.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,030.00
Rate for Payer: UHCCP Medicaid	$1,015.00

PF FULL FACE PP VISIT 1 50%

Professional

Both

$3,699.00

Hospital Charge Code	22200308
Hospital Revenue Code	222
Min. Negotiated Rate	$1,294.65
Max. Negotiated Rate	$3,699.00
Rate for Payer: Buckeye Medicare Advantage	$3,699.00
Rate for Payer: Cash Price	$1,849.50
Rate for Payer: Multiplan PHCS	$2,219.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,589.30
Rate for Payer: UHCCP Medicaid	$1,294.65

PF Full Face -PP Visit 2/3 25%

Professional

Both

$1,848.00

Hospital Charge Code	22200519
Hospital Revenue Code	222
Min. Negotiated Rate	$646.80
Max. Negotiated Rate	$1,848.00
Rate for Payer: Buckeye Medicare Advantage	$1,848.00
Rate for Payer: Cash Price	$924.00
Rate for Payer: Multiplan PHCS	$1,108.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,293.60
Rate for Payer: UHCCP Medicaid	$646.80

PF NECK

Professional

Both

$900.00

Hospital Charge Code	22200309
Hospital Revenue Code	222
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$900.00
Rate for Payer: Buckeye Medicare Advantage	$900.00
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

PF Neck - PP #1 50%

Professional

Both

$1,149.00

Hospital Charge Code	22200310
Hospital Revenue Code	222
Min. Negotiated Rate	$402.15
Max. Negotiated Rate	$1,149.00
Rate for Payer: Buckeye Medicare Advantage	$1,149.00
Rate for Payer: Cash Price	$574.50
Rate for Payer: Multiplan PHCS	$689.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$804.30
Rate for Payer: UHCCP Medicaid	$402.15

PF Neck - PP #2/3 25%

Professional

Both

$573.00

Hospital Charge Code	22200520
Hospital Revenue Code	222
Min. Negotiated Rate	$200.55
Max. Negotiated Rate	$573.00
Rate for Payer: Buckeye Medicare Advantage	$573.00
Rate for Payer: Cash Price	$286.50
Rate for Payer: Multiplan PHCS	$343.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$401.10
Rate for Payer: UHCCP Medicaid	$200.55

PF PERIORAL

Professional

Both

$1,200.00

Hospital Charge Code	22200315
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Buckeye Medicare Advantage	$1,200.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$840.00
Rate for Payer: UHCCP Medicaid	$420.00

PF Perioral - PP #1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200316
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,530.00
Rate for Payer: Buckeye Medicare Advantage	$1,530.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Multiplan PHCS	$918.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,071.00
Rate for Payer: UHCCP Medicaid	$535.50

PF Perioral - PP #2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200523
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$765.00
Rate for Payer: Buckeye Medicare Advantage	$765.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Multiplan PHCS	$459.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$535.50
Rate for Payer: UHCCP Medicaid	$267.75

PF ScarRdctn11-15cm-PP#2/3 25%

Professional

Both

$63.00

Hospital Charge Code	22200524
Hospital Revenue Code	222
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$63.00
Rate for Payer: Buckeye Medicare Advantage	$63.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Multiplan PHCS	$37.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$44.10
Rate for Payer: UHCCP Medicaid	$22.05

PF Scar Rdctn BBL -PP#1 50%

Professional

Both

$256.00

Hospital Charge Code	22200320
Hospital Revenue Code	222
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$256.00
Rate for Payer: Buckeye Medicare Advantage	$256.00
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

PF Scar Rdctn BBL -PP#2/3 25%

Professional

Both

$127.00

Hospital Charge Code	22200525
Hospital Revenue Code	222
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$127.00
Rate for Payer: Buckeye Medicare Advantage	$127.00
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

PF Scar Re 10 cm less PP#1 50%

Professional

Both

$129.00

Hospital Charge Code	22200702
Hospital Revenue Code	222
Min. Negotiated Rate	$45.15
Max. Negotiated Rate	$129.00
Rate for Payer: Buckeye Medicare Advantage	$129.00
Rate for Payer: Cash Price	$64.50
Rate for Payer: Multiplan PHCS	$77.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$90.30
Rate for Payer: UHCCP Medicaid	$45.15

PF Scar Re 10cm/less PP#2/3 25

Professional

Both

$63.00

Hospital Charge Code	22200703
Hospital Revenue Code	222
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$63.00
Rate for Payer: Buckeye Medicare Advantage	$63.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Multiplan PHCS	$37.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$44.10
Rate for Payer: UHCCP Medicaid	$22.05

PF Scar Redctn11-15cm-PP#1 50%

Professional

Both

$129.00

Hospital Charge Code	22200318
Hospital Revenue Code	222
Min. Negotiated Rate	$45.15
Max. Negotiated Rate	$129.00
Rate for Payer: Buckeye Medicare Advantage	$129.00
Rate for Payer: Cash Price	$64.50
Rate for Payer: Multiplan PHCS	$77.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$90.30
Rate for Payer: UHCCP Medicaid	$45.15

PF Scar Reduction 10cm or less

Professional

Both

$100.00

Hospital Charge Code	22200701
Hospital Revenue Code	222
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$100.00
Rate for Payer: Buckeye Medicare Advantage	$100.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Multiplan PHCS	$60.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$70.00
Rate for Payer: UHCCP Medicaid	$35.00

PF Scar Reduction 11-15 cm

Professional

Both

$100.00

Hospital Charge Code	22200317
Hospital Revenue Code	222
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$100.00
Rate for Payer: Buckeye Medicare Advantage	$100.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Multiplan PHCS	$60.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$70.00
Rate for Payer: UHCCP Medicaid	$35.00

PF Scar Reduction BBL Add-On

Professional

Both

$200.00

Hospital Charge Code	22200319
Hospital Revenue Code	222
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$200.00
Rate for Payer: Buckeye Medicare Advantage	$200.00
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

PHAR STRESS/DOBUTAMiNE

Facility

$1,166.00

Service Code	HCPCS 93017
Hospital Charge Code	48200005
Hospital Revenue Code	482
Min. Negotiated Rate	$151.58
Max. Negotiated Rate	$1,119.36
Rate for Payer: Aetna Commercial	$897.82
Rate for Payer: Anthem POS/PPO/Traditional	$909.48
Rate for Payer: Cash Price	$583.00
Rate for Payer: Cigna Commercial	$967.78
Rate for Payer: First Health Commercial	$1,107.70
Rate for Payer: Humana Commercial	$991.10
Rate for Payer: Medical Mutual Of Ohio HMO	$956.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$860.51
Rate for Payer: Molina Healthcare Benefit Exchange	$349.80
Rate for Payer: Ohio Health Choice Commercial	$1,026.08
Rate for Payer: Ohio Health Group HMO	$874.50
Rate for Payer: Ohio Health Group PPO Differential	$233.20
Rate for Payer: Ohio Health Group PPO No Differential	$151.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$361.46
Rate for Payer: PHCS Commercial	$1,119.36
Rate for Payer: United Healthcare All Payer	$1,026.08

PHAR STRESS/DOBUTAMiNE

Facility

$1,166.00

Service Code	HCPCS 93017
Hospital Charge Code	48200005
Hospital Revenue Code	482
Min. Negotiated Rate	$151.58
Max. Negotiated Rate	$1,119.36
Rate for Payer: Aetna Commercial	$897.82
Rate for Payer: Anthem Medicaid	$400.99
Rate for Payer: Anthem Medicare Advantage/PPO	$271.43
Rate for Payer: Anthem POS/PPO/Traditional	$909.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$380.00
Rate for Payer: CareSource Just4Me Medicare	$366.43
Rate for Payer: Cash Price	$583.00
Rate for Payer: Cash Price	$583.00
Rate for Payer: Cigna Commercial	$967.78
Rate for Payer: First Health Commercial	$1,107.70
Rate for Payer: Humana Commercial	$991.10
Rate for Payer: Humana KY Medicaid	$400.99
Rate for Payer: Humana Medicare Advantage	$271.43
Rate for Payer: Kentucky WC Medicaid	$405.07
Rate for Payer: Medical Mutual Of Ohio HMO	$956.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$860.51
Rate for Payer: Molina Healthcare Benefit Exchange	$325.72
Rate for Payer: Molina Healthcare Medicaid	$409.03
Rate for Payer: Ohio Health Choice Commercial	$1,026.08
Rate for Payer: Ohio Health Group HMO	$874.50
Rate for Payer: Ohio Health Group PPO Differential	$233.20
Rate for Payer: Ohio Health Group PPO No Differential	$151.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$361.46
Rate for Payer: PHCS Commercial	$1,119.36
Rate for Payer: United Healthcare All Payer	$1,026.08

PHASE ONE REC 1ST 1/2HR

Facility

$1,746.00

Hospital Charge Code	71000002
Hospital Revenue Code	710
Min. Negotiated Rate	$226.98
Max. Negotiated Rate	$1,676.16
Rate for Payer: Aetna Commercial	$1,344.42
Rate for Payer: Anthem Medicaid	$600.45
Rate for Payer: Anthem POS/PPO/Traditional	$1,361.88
Rate for Payer: Cash Price	$873.00
Rate for Payer: Cigna Commercial	$1,449.18
Rate for Payer: First Health Commercial	$1,658.70
Rate for Payer: Humana Commercial	$1,484.10
Rate for Payer: Humana KY Medicaid	$600.45
Rate for Payer: Kentucky WC Medicaid	$606.56
Rate for Payer: Medical Mutual Of Ohio HMO	$1,431.72
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,288.55
Rate for Payer: Molina Healthcare Benefit Exchange	$523.80
Rate for Payer: Molina Healthcare Medicaid	$612.50
Rate for Payer: Ohio Health Choice Commercial	$1,536.48
Rate for Payer: Ohio Health Group HMO	$1,309.50
Rate for Payer: Ohio Health Group PPO Differential	$349.20
Rate for Payer: Ohio Health Group PPO No Differential	$226.98
Rate for Payer: Ohio Health Group PPO SOMC Employees	$541.26
Rate for Payer: PHCS Commercial	$1,676.16
Rate for Payer: United Healthcare All Payer	$1,536.48

PHASE ONE REC 1ST 1/2HR

Facility

$1,746.00

Hospital Charge Code	71000002
Hospital Revenue Code	710
Min. Negotiated Rate	$226.98
Max. Negotiated Rate	$1,676.16
Rate for Payer: Aetna Commercial	$1,344.42
Rate for Payer: Anthem POS/PPO/Traditional	$1,361.88
Rate for Payer: Cash Price	$873.00
Rate for Payer: Cigna Commercial	$1,449.18
Rate for Payer: First Health Commercial	$1,658.70
Rate for Payer: Humana Commercial	$1,484.10
Rate for Payer: Medical Mutual Of Ohio HMO	$1,431.72
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,288.55
Rate for Payer: Molina Healthcare Benefit Exchange	$523.80
Rate for Payer: Ohio Health Choice Commercial	$1,536.48
Rate for Payer: Ohio Health Group HMO	$1,309.50
Rate for Payer: Ohio Health Group PPO Differential	$349.20
Rate for Payer: Ohio Health Group PPO No Differential	$226.98
Rate for Payer: Ohio Health Group PPO SOMC Employees	$541.26
Rate for Payer: PHCS Commercial	$1,676.16
Rate for Payer: United Healthcare All Payer	$1,536.48

PHASE ONE REC EA ADDL 1/2HR

Facility

$873.00

Hospital Charge Code	71000001
Hospital Revenue Code	710
Min. Negotiated Rate	$113.49
Max. Negotiated Rate	$838.08
Rate for Payer: Aetna Commercial	$672.21
Rate for Payer: Anthem POS/PPO/Traditional	$680.94
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cigna Commercial	$724.59
Rate for Payer: First Health Commercial	$829.35
Rate for Payer: Humana Commercial	$742.05
Rate for Payer: Medical Mutual Of Ohio HMO	$715.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$644.27
Rate for Payer: Molina Healthcare Benefit Exchange	$261.90
Rate for Payer: Ohio Health Choice Commercial	$768.24
Rate for Payer: Ohio Health Group HMO	$654.75
Rate for Payer: Ohio Health Group PPO Differential	$174.60
Rate for Payer: Ohio Health Group PPO No Differential	$113.49
Rate for Payer: Ohio Health Group PPO SOMC Employees	$270.63
Rate for Payer: PHCS Commercial	$838.08
Rate for Payer: United Healthcare All Payer	$768.24

PHASE ONE REC EA ADDL 1/2HR

Facility

$873.00

Hospital Charge Code	71000001
Hospital Revenue Code	710
Min. Negotiated Rate	$113.49
Max. Negotiated Rate	$838.08
Rate for Payer: Aetna Commercial	$672.21
Rate for Payer: Anthem Medicaid	$300.22
Rate for Payer: Anthem POS/PPO/Traditional	$680.94
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cigna Commercial	$724.59
Rate for Payer: First Health Commercial	$829.35
Rate for Payer: Humana Commercial	$742.05
Rate for Payer: Humana KY Medicaid	$300.22
Rate for Payer: Kentucky WC Medicaid	$303.28
Rate for Payer: Medical Mutual Of Ohio HMO	$715.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$644.27
Rate for Payer: Molina Healthcare Benefit Exchange	$261.90
Rate for Payer: Molina Healthcare Medicaid	$306.25
Rate for Payer: Ohio Health Choice Commercial	$768.24
Rate for Payer: Ohio Health Group HMO	$654.75
Rate for Payer: Ohio Health Group PPO Differential	$174.60
Rate for Payer: Ohio Health Group PPO No Differential	$113.49
Rate for Payer: Ohio Health Group PPO SOMC Employees	$270.63
Rate for Payer: PHCS Commercial	$838.08
Rate for Payer: United Healthcare All Payer	$768.24

PHASE TWO RECOV PER 1/2 HR

Facility

$35.00

Hospital Charge Code	71000003
Hospital Revenue Code	710
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$33.60
Rate for Payer: Aetna Commercial	$26.95
Rate for Payer: Anthem Medicaid	$12.04
Rate for Payer: Anthem POS/PPO/Traditional	$27.30
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cigna Commercial	$29.05
Rate for Payer: First Health Commercial	$33.25
Rate for Payer: Humana Commercial	$29.75
Rate for Payer: Humana KY Medicaid	$12.04
Rate for Payer: Kentucky WC Medicaid	$12.16
Rate for Payer: Medical Mutual Of Ohio HMO	$28.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$25.83
Rate for Payer: Molina Healthcare Benefit Exchange	$10.50
Rate for Payer: Molina Healthcare Medicaid	$12.28
Rate for Payer: Ohio Health Choice Commercial	$30.80
Rate for Payer: Ohio Health Group HMO	$26.25
Rate for Payer: Ohio Health Group PPO Differential	$7.00
Rate for Payer: Ohio Health Group PPO No Differential	$4.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10.85
Rate for Payer: PHCS Commercial	$33.60
Rate for Payer: United Healthcare All Payer	$30.80

Know your out-of-pocket cost for care.

All Charges