Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

BACITRACIN OINTMENT 1OZ

Facility

$0.08

Service Code	NDC 68001047747
Hospital Charge Code	25000305
Hospital Revenue Code	637
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna Commercial	$0.06
Rate for Payer: Anthem POS/PPO/Traditional	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna Commercial	$0.07
Rate for Payer: First Health Commercial	$0.08
Rate for Payer: Humana Commercial	$0.07
Rate for Payer: Medical Mutual Of Ohio HMO	$0.07
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$0.06
Rate for Payer: Molina Healthcare Benefit Exchange	$0.02
Rate for Payer: Ohio Health Choice Commercial	$0.07
Rate for Payer: Ohio Health Group HMO	$0.06
Rate for Payer: Ohio Health Group PPO Differential	$0.02
Rate for Payer: Ohio Health Group PPO No Differential	$0.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$0.02
Rate for Payer: PHCS Commercial	$0.08
Rate for Payer: United Healthcare All Payer	$0.07

BACITRACIN OINTMENT 1OZ

Facility

$0.08

Service Code	NDC 68001047747
Hospital Charge Code	25000305
Hospital Revenue Code	637
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna Commercial	$0.06
Rate for Payer: Anthem Medicaid	$0.03
Rate for Payer: Anthem POS/PPO/Traditional	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna Commercial	$0.07
Rate for Payer: First Health Commercial	$0.08
Rate for Payer: Humana Commercial	$0.07
Rate for Payer: Humana KY Medicaid	$0.03
Rate for Payer: Kentucky WC Medicaid	$0.03
Rate for Payer: Medical Mutual Of Ohio HMO	$0.07
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$0.06
Rate for Payer: Molina Healthcare Benefit Exchange	$0.02
Rate for Payer: Molina Healthcare Medicaid	$0.03
Rate for Payer: Ohio Health Choice Commercial	$0.07
Rate for Payer: Ohio Health Group HMO	$0.06
Rate for Payer: Ohio Health Group PPO Differential	$0.02
Rate for Payer: Ohio Health Group PPO No Differential	$0.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$0.02
Rate for Payer: PHCS Commercial	$0.08
Rate for Payer: United Healthcare All Payer	$0.07

BACITRACIN OINTMENT PKT. .9GM

Facility

$4.42

Service Code	NDC 69968006009
Hospital Charge Code	25002870
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$4.24
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: Anthem Medicaid	$1.52
Rate for Payer: Anthem POS/PPO/Traditional	$3.45
Rate for Payer: Cash Price	$2.21
Rate for Payer: Cigna Commercial	$3.67
Rate for Payer: First Health Commercial	$4.20
Rate for Payer: Humana Commercial	$3.76
Rate for Payer: Humana KY Medicaid	$1.52
Rate for Payer: Kentucky WC Medicaid	$1.54
Rate for Payer: Medical Mutual Of Ohio HMO	$3.62
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.26
Rate for Payer: Molina Healthcare Benefit Exchange	$1.33
Rate for Payer: Molina Healthcare Medicaid	$1.55
Rate for Payer: Ohio Health Choice Commercial	$3.89
Rate for Payer: Ohio Health Group HMO	$3.32
Rate for Payer: Ohio Health Group PPO Differential	$0.88
Rate for Payer: Ohio Health Group PPO No Differential	$0.57
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.37
Rate for Payer: PHCS Commercial	$4.24
Rate for Payer: United Healthcare All Payer	$3.89

BACITRACIN OINTMENT PKT. .9GM

Facility

$4.42

Service Code	NDC 69968006009
Hospital Charge Code	25002870
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$4.24
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: Anthem POS/PPO/Traditional	$3.45
Rate for Payer: Cash Price	$2.21
Rate for Payer: Cigna Commercial	$3.67
Rate for Payer: First Health Commercial	$4.20
Rate for Payer: Humana Commercial	$3.76
Rate for Payer: Medical Mutual Of Ohio HMO	$3.62
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.26
Rate for Payer: Molina Healthcare Benefit Exchange	$1.33
Rate for Payer: Ohio Health Choice Commercial	$3.89
Rate for Payer: Ohio Health Group HMO	$3.32
Rate for Payer: Ohio Health Group PPO Differential	$0.88
Rate for Payer: Ohio Health Group PPO No Differential	$0.57
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.37
Rate for Payer: PHCS Commercial	$4.24
Rate for Payer: United Healthcare All Payer	$3.89

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$23,029.09

Service Code	MSDRG 519
Min. Negotiated Rate	$15,626.88
Max. Negotiated Rate	$23,029.09
Rate for Payer: Anthem Medicaid	$15,626.88
Rate for Payer: Anthem Medicare Advantage/PPO	$16,449.35
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,029.09
Rate for Payer: CareSource Just4Me Medicare	$22,206.62
Rate for Payer: Humana KY Medicaid	$15,626.88
Rate for Payer: Humana Medicare Advantage	$16,449.35
Rate for Payer: Kentucky WC Medicaid	$15,783.15
Rate for Payer: Molina Healthcare Benefit Exchange	$19,739.22
Rate for Payer: Molina Healthcare Medicaid	$15,939.42

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$42,719.50

Service Code	MSDRG 518
Min. Negotiated Rate	$28,988.23
Max. Negotiated Rate	$42,719.50
Rate for Payer: Anthem Medicaid	$28,988.23
Rate for Payer: Anthem Medicare Advantage/PPO	$30,513.93
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$42,719.50
Rate for Payer: CareSource Just4Me Medicare	$41,193.81
Rate for Payer: Humana KY Medicaid	$28,988.23
Rate for Payer: Humana Medicare Advantage	$30,513.93
Rate for Payer: Kentucky WC Medicaid	$29,278.12
Rate for Payer: Molina Healthcare Benefit Exchange	$36,616.72
Rate for Payer: Molina Healthcare Medicaid	$29,568.00

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$16,745.97

Service Code	MSDRG 520
Min. Negotiated Rate	$11,363.34
Max. Negotiated Rate	$16,745.97
Rate for Payer: Anthem Medicaid	$11,363.34
Rate for Payer: Anthem Medicare Advantage/PPO	$11,961.41
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$16,745.97
Rate for Payer: CareSource Just4Me Medicare	$16,147.90
Rate for Payer: Humana KY Medicaid	$11,363.34
Rate for Payer: Humana Medicare Advantage	$11,961.41
Rate for Payer: Kentucky WC Medicaid	$11,476.97
Rate for Payer: Molina Healthcare Benefit Exchange	$14,353.69
Rate for Payer: Molina Healthcare Medicaid	$11,590.61

Back Full Laser Hair Removal

Professional

Both

$475.00

Hospital Charge Code	22200183
Hospital Revenue Code	222
Min. Negotiated Rate	$166.25
Max. Negotiated Rate	$475.00
Rate for Payer: Buckeye Medicare Advantage	$475.00
Rate for Payer: Cash Price	$237.50
Rate for Payer: Multiplan PHCS	$285.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$332.50
Rate for Payer: UHCCP Medicaid	$166.25

Back Full Lsr HairRem-PP#1 50%

Professional

Both

$607.00

Hospital Charge Code	22200347
Hospital Revenue Code	222
Min. Negotiated Rate	$212.45
Max. Negotiated Rate	$607.00
Rate for Payer: Buckeye Medicare Advantage	$607.00
Rate for Payer: Cash Price	$303.50
Rate for Payer: Multiplan PHCS	$364.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$424.90
Rate for Payer: UHCCP Medicaid	$212.45

Back FulLsr HairRem-PP#2/3 25%

Professional

Both

$302.00

Hospital Charge Code	22200463
Hospital Revenue Code	222
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$302.00
Rate for Payer: Buckeye Medicare Advantage	$302.00
Rate for Payer: Cash Price	$151.00
Rate for Payer: Multiplan PHCS	$181.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$211.40
Rate for Payer: UHCCP Medicaid	$105.70

Back Laser Hair Removal

Professional

Both

$250.00

Hospital Charge Code	22200212
Hospital Revenue Code	222
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$250.00
Rate for Payer: Buckeye Medicare Advantage	$250.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Multiplan PHCS	$150.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$175.00
Rate for Payer: UHCCP Medicaid	$87.50

Back Lsr Hair Rem-PP #1 50%

Professional

Both

$319.00

Hospital Charge Code	22200213
Hospital Revenue Code	222
Min. Negotiated Rate	$111.65
Max. Negotiated Rate	$319.00
Rate for Payer: Buckeye Medicare Advantage	$319.00
Rate for Payer: Cash Price	$159.50
Rate for Payer: Multiplan PHCS	$191.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$223.30
Rate for Payer: UHCCP Medicaid	$111.65

Back Lsr Hair Rem-PP #2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200472
Hospital Revenue Code	222
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$159.00
Rate for Payer: Buckeye Medicare Advantage	$159.00
Rate for Payer: Cash Price	$79.50
Rate for Payer: Multiplan PHCS	$95.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$111.30
Rate for Payer: UHCCP Medicaid	$55.65

Back partial Laser Hair Remova

Professional

Both

$250.00

Hospital Charge Code	22200182
Hospital Revenue Code	222
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$250.00
Rate for Payer: Buckeye Medicare Advantage	$250.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Multiplan PHCS	$150.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$175.00
Rate for Payer: UHCCP Medicaid	$87.50

Back partl LsrHairRem-PP#1 50%

Professional

Both

$319.00

Hospital Charge Code	22200346
Hospital Revenue Code	222
Min. Negotiated Rate	$111.65
Max. Negotiated Rate	$319.00
Rate for Payer: Buckeye Medicare Advantage	$319.00
Rate for Payer: Cash Price	$159.50
Rate for Payer: Multiplan PHCS	$191.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$223.30
Rate for Payer: UHCCP Medicaid	$111.65

Back prtlLsrHairRem-PP#2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200462
Hospital Revenue Code	222
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$159.00
Rate for Payer: Buckeye Medicare Advantage	$159.00
Rate for Payer: Cash Price	$79.50
Rate for Payer: Multiplan PHCS	$95.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$111.30
Rate for Payer: UHCCP Medicaid	$55.65

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$27,890.87

Service Code	MSDRG 095
Min. Negotiated Rate	$18,925.95
Max. Negotiated Rate	$27,890.87
Rate for Payer: Anthem Medicaid	$18,925.95
Rate for Payer: Anthem Medicare Advantage/PPO	$19,922.05
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$27,890.87
Rate for Payer: CareSource Just4Me Medicare	$26,894.77
Rate for Payer: Humana KY Medicaid	$18,925.95
Rate for Payer: Humana Medicare Advantage	$19,922.05
Rate for Payer: Kentucky WC Medicaid	$19,115.21
Rate for Payer: Molina Healthcare Benefit Exchange	$23,906.46
Rate for Payer: Molina Healthcare Medicaid	$19,304.47

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$42,379.11

Service Code	MSDRG 094
Min. Negotiated Rate	$28,757.25
Max. Negotiated Rate	$42,379.11
Rate for Payer: Anthem Medicaid	$28,757.25
Rate for Payer: Anthem Medicare Advantage/PPO	$30,270.79
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$42,379.11
Rate for Payer: CareSource Just4Me Medicare	$40,865.57
Rate for Payer: Humana KY Medicaid	$28,757.25
Rate for Payer: Humana Medicare Advantage	$30,270.79
Rate for Payer: Kentucky WC Medicaid	$29,044.82
Rate for Payer: Molina Healthcare Benefit Exchange	$36,324.95
Rate for Payer: Molina Healthcare Medicaid	$29,332.40

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$25,498.56

Service Code	MSDRG 096
Min. Negotiated Rate	$17,302.60
Max. Negotiated Rate	$25,498.56
Rate for Payer: Anthem Medicaid	$17,302.60
Rate for Payer: Anthem Medicare Advantage/PPO	$18,213.26
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$25,498.56
Rate for Payer: CareSource Just4Me Medicare	$24,587.90
Rate for Payer: Humana KY Medicaid	$17,302.60
Rate for Payer: Humana Medicare Advantage	$18,213.26
Rate for Payer: Kentucky WC Medicaid	$17,475.62
Rate for Payer: Molina Healthcare Benefit Exchange	$21,855.91
Rate for Payer: Molina Healthcare Medicaid	$17,648.65

BACTERIAL IDENTIFICATION

Professional

Both

$80.00

Service Code	HCPCS 87077
Hospital Charge Code	30001261
Hospital Revenue Code	306
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$9.93
Rate for Payer: Buckeye Medicare Advantage	$80.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna Commercial	$7.19
Rate for Payer: Healthspan PPO	$8.47
Rate for Payer: Multiplan PHCS	$48.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$56.00
Rate for Payer: UHCCP Medicaid	$28.00
Rate for Payer: Wellcare CHIP/Medicaid	$4.85

BACTERIAL IDENTIFICATION

Facility

$80.00

Service Code	HCPCS 87077
Hospital Charge Code	30001261
Hospital Revenue Code	306
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem Medicaid	$8.08
Rate for Payer: Anthem Medicare Advantage/PPO	$8.08
Rate for Payer: Anthem POS/PPO/Traditional	$64.24
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11.31
Rate for Payer: CareSource Just4Me Medicare	$8.08
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna Commercial	$66.40
Rate for Payer: First Health Commercial	$76.00
Rate for Payer: Humana Commercial	$68.00
Rate for Payer: Humana KY Medicaid	$8.08
Rate for Payer: Humana Medicare Advantage	$8.08
Rate for Payer: Kentucky WC Medicaid	$8.16
Rate for Payer: Medical Mutual Of Ohio HMO	$65.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$59.04
Rate for Payer: Molina Healthcare Benefit Exchange	$9.70
Rate for Payer: Molina Healthcare Medicaid	$8.24
Rate for Payer: Ohio Health Choice Commercial	$70.40
Rate for Payer: Ohio Health Group HMO	$60.00
Rate for Payer: Ohio Health Group PPO Differential	$16.00
Rate for Payer: Ohio Health Group PPO No Differential	$10.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24.80
Rate for Payer: PHCS Commercial	$76.80
Rate for Payer: United Healthcare All Payer	$70.40

BACTERIAL IDENTIFICATION

Facility

$80.00

Service Code	HCPCS 87077
Hospital Charge Code	30001261
Hospital Revenue Code	306
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem POS/PPO/Traditional	$64.24
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna Commercial	$66.40
Rate for Payer: First Health Commercial	$76.00
Rate for Payer: Humana Commercial	$68.00
Rate for Payer: Medical Mutual Of Ohio HMO	$65.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$59.04
Rate for Payer: Molina Healthcare Benefit Exchange	$24.00
Rate for Payer: Ohio Health Choice Commercial	$70.40
Rate for Payer: Ohio Health Group HMO	$60.00
Rate for Payer: Ohio Health Group PPO Differential	$16.00
Rate for Payer: Ohio Health Group PPO No Differential	$10.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24.80
Rate for Payer: PHCS Commercial	$76.80
Rate for Payer: United Healthcare All Payer	$70.40

BACTERLOSTATIC WTR INJ VL 30ML

Facility

$77.90

Service Code	NDC 409397703
Hospital Charge Code	25002871
Hospital Revenue Code	250
Min. Negotiated Rate	$10.13
Max. Negotiated Rate	$74.78
Rate for Payer: Aetna Commercial	$59.98
Rate for Payer: Anthem POS/PPO/Traditional	$60.76
Rate for Payer: Cash Price	$38.95
Rate for Payer: Cigna Commercial	$64.66
Rate for Payer: First Health Commercial	$74.00
Rate for Payer: Humana Commercial	$66.22
Rate for Payer: Medical Mutual Of Ohio HMO	$63.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$57.49
Rate for Payer: Molina Healthcare Benefit Exchange	$23.37
Rate for Payer: Ohio Health Choice Commercial	$68.55
Rate for Payer: Ohio Health Group HMO	$58.42
Rate for Payer: Ohio Health Group PPO Differential	$15.58
Rate for Payer: Ohio Health Group PPO No Differential	$10.13
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24.15
Rate for Payer: PHCS Commercial	$74.78
Rate for Payer: United Healthcare All Payer	$68.55

BACTERLOSTATIC WTR INJ VL 30ML

Facility

$77.90

Service Code	NDC 409397703
Hospital Charge Code	25002871
Hospital Revenue Code	250
Min. Negotiated Rate	$10.13
Max. Negotiated Rate	$74.78
Rate for Payer: Kentucky WC Medicaid	$27.06
Rate for Payer: Medical Mutual Of Ohio HMO	$63.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$57.49
Rate for Payer: Molina Healthcare Benefit Exchange	$23.37
Rate for Payer: Molina Healthcare Medicaid	$27.33
Rate for Payer: Ohio Health Choice Commercial	$68.55
Rate for Payer: Ohio Health Group HMO	$58.42
Rate for Payer: Ohio Health Group PPO Differential	$15.58
Rate for Payer: Ohio Health Group PPO No Differential	$10.13
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24.15
Rate for Payer: PHCS Commercial	$74.78
Rate for Payer: United Healthcare All Payer	$68.55
Rate for Payer: Aetna Commercial	$59.98
Rate for Payer: Anthem Medicaid	$26.79
Rate for Payer: Anthem POS/PPO/Traditional	$60.76
Rate for Payer: Cash Price	$38.95
Rate for Payer: Cigna Commercial	$64.66
Rate for Payer: First Health Commercial	$74.00
Rate for Payer: Humana Commercial	$66.22
Rate for Payer: Humana KY Medicaid	$26.79

BACTRIM DS (SULFAM-TR TAB/1TAB

Facility

$4.46

Service Code	NDC 60687061401
Hospital Charge Code	25000307
Hospital Revenue Code	637
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$3.43
Rate for Payer: Anthem POS/PPO/Traditional	$3.48
Rate for Payer: Cash Price	$2.23
Rate for Payer: Cigna Commercial	$3.70
Rate for Payer: First Health Commercial	$4.24
Rate for Payer: Humana Commercial	$3.79
Rate for Payer: Medical Mutual Of Ohio HMO	$3.66
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1.34
Rate for Payer: Ohio Health Choice Commercial	$3.92
Rate for Payer: Ohio Health Group HMO	$3.34
Rate for Payer: Ohio Health Group PPO Differential	$0.89
Rate for Payer: Ohio Health Group PPO No Differential	$0.58
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1.38
Rate for Payer: PHCS Commercial	$4.28
Rate for Payer: United Healthcare All Payer	$3.92

Know your out-of-pocket cost for care.

All Charges