Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

BBLP Neck - PP #2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200488
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

BBLP Shoulders

Professional

Both

$350.00

Hospital Charge Code	22200244
Hospital Revenue Code	222
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$350.00
Rate for Payer: Buckeye Medicare Advantage	$350.00
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

BBLP Shoulders-PP#1 50%

Professional

Both

$446.00

Hospital Charge Code	22200245
Hospital Revenue Code	222
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$446.00
Rate for Payer: Buckeye Medicare Advantage	$446.00
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

BBLP Shoulders-PP#2/ 3 25%

Professional

Both

$223.00

Hospital Charge Code	22200489
Hospital Revenue Code	222
Min. Negotiated Rate	$78.05
Max. Negotiated Rate	$223.00
Rate for Payer: Buckeye Medicare Advantage	$223.00
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

BBLP SPOT TREATMENT UP TO 5

Professional

Both

$100.00

Hospital Charge Code	22200260
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

BBLP UPPER ARMS

Professional

Both

$700.00

Hospital Charge Code	22200248
Hospital Revenue Code	222
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$700.00
Rate for Payer: Buckeye Medicare Advantage	$700.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Multiplan PHCS	$420.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$490.00
Rate for Payer: UHCCP Medicaid	$245.00

BBLP Upper Arms-PP #1 50%

Professional

Both

$893.00

Hospital Charge Code	22200249
Hospital Revenue Code	222
Min. Negotiated Rate	$312.55
Max. Negotiated Rate	$893.00
Rate for Payer: Buckeye Medicare Advantage	$893.00
Rate for Payer: Cash Price	$446.50
Rate for Payer: Multiplan PHCS	$535.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$625.10
Rate for Payer: UHCCP Medicaid	$312.55

BBLP Upper Arms-PP #2/3 25%

Professional

Both

$446.00

Hospital Charge Code	22200491
Hospital Revenue Code	222
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$446.00
Rate for Payer: Buckeye Medicare Advantage	$446.00
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

BBLP Upper legs/thigh-PP#1 50%

Professional

Both

$1,659.00

Hospital Charge Code	22200255
Hospital Revenue Code	222
Min. Negotiated Rate	$580.65
Max. Negotiated Rate	$1,659.00
Rate for Payer: Buckeye Medicare Advantage	$1,659.00
Rate for Payer: Cash Price	$829.50
Rate for Payer: Multiplan PHCS	$995.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,161.30
Rate for Payer: UHCCP Medicaid	$580.65

BBLP UPPER LEGS/THIGHS

Professional

Both

$1,300.00

Hospital Charge Code	22200254
Hospital Revenue Code	222
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$1,300.00
Rate for Payer: Buckeye Medicare Advantage	$1,300.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Multiplan PHCS	$780.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$910.00
Rate for Payer: UHCCP Medicaid	$455.00

BBLP Uppr leg/thigh-PP#2/3 25%

Professional

Both

$828.00

Hospital Charge Code	22200494
Hospital Revenue Code	222
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$828.00
Rate for Payer: Buckeye Medicare Advantage	$828.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Multiplan PHCS	$496.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$579.60
Rate for Payer: UHCCP Medicaid	$289.80

BBLV Chest

Professional

Both

$250.00

Hospital Charge Code	22200275
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

BBLV Chest - PP #1 50%

Professional

Both

$319.00

Hospital Charge Code	22200276
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

BBLV Chest - PP #2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200502
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

BBLV Full Face

Professional

Both

$250.00

Hospital Charge Code	22200269
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

BBLV Full Face-PP #1 50%

Professional

Both

$319.00

Hospital Charge Code	22200270
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

BBLV Full Face-PP#2/3 25%

Professional

Both

$159.00

Hospital Charge Code	22200499
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

BBLV Neck

Professional

Both

$200.00

Hospital Charge Code	22200273
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

BBLV Neck - PP #1 50%

Professional

Both

$256.00

Hospital Charge Code	22200274
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

BBLV Neck - PP #2/3 25%

Professional

Both

$127.00

Hospital Charge Code	22200501
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

BBLV Partial Face

Professional

Both

$95.00

Hospital Charge Code	22200271
Hospital Revenue Code	222
Min. Negotiated Rate	$33.25
Max. Negotiated Rate	$95.00
Rate for Payer: Buckeye Medicare Advantage	$95.00
Rate for Payer: Cash Price	$47.50
Rate for Payer: Multiplan PHCS	$57.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$66.50
Rate for Payer: UHCCP Medicaid	$33.25

BBLV Partial Face-PP#1 50%

Professional

Both

$122.00

Hospital Charge Code	22200272
Hospital Revenue Code	222
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$122.00
Rate for Payer: Buckeye Medicare Advantage	$122.00
Rate for Payer: Cash Price	$61.00
Rate for Payer: Multiplan PHCS	$73.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$85.40
Rate for Payer: UHCCP Medicaid	$42.70

BBLV Partial Face-PP#2/3 25%

Professional

Both

$60.00

Hospital Charge Code	22200500
Hospital Revenue Code	222
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$60.00
Rate for Payer: Buckeye Medicare Advantage	$60.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Multiplan PHCS	$36.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$42.00
Rate for Payer: UHCCP Medicaid	$21.00

BBLV SPOT TREATMENT UP TO 5

Professional

Both

$100.00

Hospital Charge Code	22200277
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

BCG Live 1mg (50mg SDV)

Facility

$925.85

Service Code	HCPCS J9030
Hospital Charge Code	25002561
Hospital Revenue Code	636
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$888.82
Rate for Payer: Aetna Commercial	$712.90
Rate for Payer: Anthem POS/PPO/Traditional	$722.16
Rate for Payer: Cash Price	$462.92
Rate for Payer: Cigna Commercial	$768.46
Rate for Payer: First Health Commercial	$879.56
Rate for Payer: Humana Commercial	$786.97
Rate for Payer: Medical Mutual Of Ohio HMO	$759.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$683.28
Rate for Payer: Molina Healthcare Benefit Exchange	$277.76
Rate for Payer: Ohio Health Choice Commercial	$814.75
Rate for Payer: Ohio Health Group HMO	$694.39
Rate for Payer: Ohio Health Group PPO Differential	$185.17
Rate for Payer: Ohio Health Group PPO No Differential	$120.36
Rate for Payer: Ohio Health Group PPO SOMC Employees	$287.01
Rate for Payer: PHCS Commercial	$888.82
Rate for Payer: United Healthcare All Payer	$814.75

Know your out-of-pocket cost for care.

All Charges