Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

PFC SIG RPF CEM FEM SZ 4N LT

Facility

$15,790.82

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,737.25
Max. Negotiated Rate	$15,159.19
Rate for Payer: Aetna Commercial	$12,158.93
Rate for Payer: Anthem POS/PPO/Traditional	$12,316.84
Rate for Payer: Cash Price	$7,895.41
Rate for Payer: Cigna Commercial	$13,106.38
Rate for Payer: First Health Commercial	$15,001.28
Rate for Payer: Humana Commercial	$13,422.20
Rate for Payer: Medical Mutual Of Ohio HMO	$12,948.47
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,653.63
Rate for Payer: Molina Healthcare Benefit Exchange	$4,737.25
Rate for Payer: Ohio Health Choice Commercial	$13,895.92
Rate for Payer: Ohio Health Group HMO	$11,843.11
Rate for Payer: Ohio Health Group PPO Differential	$12,632.66
Rate for Payer: Ohio Health Group PPO No Differential	$13,738.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,895.67
Rate for Payer: PHCS Commercial	$15,159.19
Rate for Payer: United Healthcare All Payer	$13,895.92

PFC SIG RPF CEM FEM SZ 4N LT

Facility

$15,790.82

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,737.25
Max. Negotiated Rate	$15,159.19
Rate for Payer: Aetna Commercial	$12,158.93
Rate for Payer: Anthem Medicaid	$5,430.46
Rate for Payer: Anthem POS/PPO/Traditional	$12,316.84
Rate for Payer: Cash Price	$7,895.41
Rate for Payer: Cigna Commercial	$13,106.38
Rate for Payer: First Health Commercial	$15,001.28
Rate for Payer: Humana Commercial	$13,422.20
Rate for Payer: Humana KY Medicaid	$5,430.46
Rate for Payer: Kentucky WC Medicaid	$5,485.73
Rate for Payer: Medical Mutual Of Ohio HMO	$12,948.47
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,653.63
Rate for Payer: Molina Healthcare Benefit Exchange	$4,737.25
Rate for Payer: Molina Healthcare Medicaid	$5,539.42
Rate for Payer: Ohio Health Choice Commercial	$13,895.92
Rate for Payer: Ohio Health Group HMO	$11,843.11
Rate for Payer: Ohio Health Group PPO Differential	$12,632.66
Rate for Payer: Ohio Health Group PPO No Differential	$13,738.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,895.67
Rate for Payer: PHCS Commercial	$15,159.19
Rate for Payer: United Healthcare All Payer	$13,895.92

PFC SIG RPF CEM FEM SZ 4N RT

Facility

$15,790.82

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,737.25
Max. Negotiated Rate	$15,159.19
Rate for Payer: Aetna Commercial	$12,158.93
Rate for Payer: Anthem Medicaid	$5,430.46
Rate for Payer: Anthem POS/PPO/Traditional	$12,316.84
Rate for Payer: Cash Price	$7,895.41
Rate for Payer: Cigna Commercial	$13,106.38
Rate for Payer: First Health Commercial	$15,001.28
Rate for Payer: Humana Commercial	$13,422.20
Rate for Payer: Humana KY Medicaid	$5,430.46
Rate for Payer: Kentucky WC Medicaid	$5,485.73
Rate for Payer: Medical Mutual Of Ohio HMO	$12,948.47
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,653.63
Rate for Payer: Molina Healthcare Benefit Exchange	$4,737.25
Rate for Payer: Molina Healthcare Medicaid	$5,539.42
Rate for Payer: Ohio Health Choice Commercial	$13,895.92
Rate for Payer: Ohio Health Group HMO	$11,843.11
Rate for Payer: Ohio Health Group PPO Differential	$12,632.66
Rate for Payer: Ohio Health Group PPO No Differential	$13,738.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,895.67
Rate for Payer: PHCS Commercial	$15,159.19
Rate for Payer: United Healthcare All Payer	$13,895.92

PFC SIG RPF CEM FEM SZ 4N RT

Facility

$15,790.82

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,737.25
Max. Negotiated Rate	$15,159.19
Rate for Payer: Aetna Commercial	$12,158.93
Rate for Payer: Anthem POS/PPO/Traditional	$12,316.84
Rate for Payer: Cash Price	$7,895.41
Rate for Payer: Cigna Commercial	$13,106.38
Rate for Payer: First Health Commercial	$15,001.28
Rate for Payer: Humana Commercial	$13,422.20
Rate for Payer: Medical Mutual Of Ohio HMO	$12,948.47
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$11,653.63
Rate for Payer: Molina Healthcare Benefit Exchange	$4,737.25
Rate for Payer: Ohio Health Choice Commercial	$13,895.92
Rate for Payer: Ohio Health Group HMO	$11,843.11
Rate for Payer: Ohio Health Group PPO Differential	$12,632.66
Rate for Payer: Ohio Health Group PPO No Differential	$13,738.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,895.67
Rate for Payer: PHCS Commercial	$15,159.19
Rate for Payer: United Healthcare All Payer	$13,895.92

PF Eyelid Full Face-PP#2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200522
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$535.50
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 EYELIDS

Professional

Both

$1,200.00

Hospital Charge Code	22200313
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$840.00
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 Eyelids Full Face-PP#1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200314
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,071.00
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 FULL FACE

Professional

Both

$2,900.00

Hospital Charge Code	22200307
Hospital Revenue Code	222
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$2,030.00
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	$2,589.30
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	$1,293.60
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	$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

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	$804.30
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	$401.10
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	$840.00
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	$1,071.00
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	$535.50
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	$44.10
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	$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

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	$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

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	$90.30
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	$44.10
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	$90.30
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	$70.00
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	$70.00
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	$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

Know your out-of-pocket cost for care.

All Charges