Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

PROZAC (FLUOXETINE) 2 20MG/5ML

Facility

$10.88

Service Code	NDC 54838052340
Hospital Charge Code	25001271
Hospital Revenue Code	637
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$10.44
Rate for Payer: Aetna Commercial	$8.38
Rate for Payer: Anthem Medicaid	$3.74
Rate for Payer: Anthem POS/PPO/Traditional	$8.49
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$9.03
Rate for Payer: First Health Commercial	$10.34
Rate for Payer: Humana Commercial	$9.25
Rate for Payer: Humana KY Medicaid	$3.74
Rate for Payer: Kentucky WC Medicaid	$3.78
Rate for Payer: Medical Mutual Of Ohio HMO	$8.92
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8.03
Rate for Payer: Molina Healthcare Benefit Exchange	$3.26
Rate for Payer: Molina Healthcare Medicaid	$3.82
Rate for Payer: Ohio Health Choice Commercial	$9.57
Rate for Payer: Ohio Health Group HMO	$8.16
Rate for Payer: Ohio Health Group PPO Differential	$8.70
Rate for Payer: Ohio Health Group PPO No Differential	$9.47
Rate for Payer: Ohio Health Group PPO SOMC Employees	$7.51
Rate for Payer: PHCS Commercial	$10.44
Rate for Payer: United Healthcare All Payer	$9.57

PROZAC (FLUOXETINE) CAP 10MG

Facility

$4.25

Service Code	NDC 50111064701
Hospital Charge Code	25001272
Hospital Revenue Code	637
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna Commercial	$3.27
Rate for Payer: Anthem Medicaid	$1.46
Rate for Payer: Anthem POS/PPO/Traditional	$3.31
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cigna Commercial	$3.53
Rate for Payer: First Health Commercial	$4.04
Rate for Payer: Humana Commercial	$3.61
Rate for Payer: Humana KY Medicaid	$1.46
Rate for Payer: Kentucky WC Medicaid	$1.48
Rate for Payer: Medical Mutual Of Ohio HMO	$3.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.14
Rate for Payer: Molina Healthcare Benefit Exchange	$1.27
Rate for Payer: Molina Healthcare Medicaid	$1.49
Rate for Payer: Ohio Health Choice Commercial	$3.74
Rate for Payer: Ohio Health Group HMO	$3.19
Rate for Payer: Ohio Health Group PPO Differential	$3.40
Rate for Payer: Ohio Health Group PPO No Differential	$3.70
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2.93
Rate for Payer: PHCS Commercial	$4.08
Rate for Payer: United Healthcare All Payer	$3.74

PROZAC (FLUOXETINE) CAP 10MG

Facility

$4.25

Service Code	NDC 50111064701
Hospital Charge Code	25001272
Hospital Revenue Code	637
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna Commercial	$3.27
Rate for Payer: Anthem POS/PPO/Traditional	$3.31
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cigna Commercial	$3.53
Rate for Payer: First Health Commercial	$4.04
Rate for Payer: Humana Commercial	$3.61
Rate for Payer: Medical Mutual Of Ohio HMO	$3.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3.14
Rate for Payer: Molina Healthcare Benefit Exchange	$1.27
Rate for Payer: Ohio Health Choice Commercial	$3.74
Rate for Payer: Ohio Health Group HMO	$3.19
Rate for Payer: Ohio Health Group PPO Differential	$3.40
Rate for Payer: Ohio Health Group PPO No Differential	$3.70
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2.93
Rate for Payer: PHCS Commercial	$4.08
Rate for Payer: United Healthcare All Payer	$3.74

PROZAC WEEKLY 90MG CAPSULE DR

Facility

$70.67

Service Code	NDC 55111028448
Hospital Charge Code	25001274
Hospital Revenue Code	637
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$67.84
Rate for Payer: Aetna Commercial	$54.42
Rate for Payer: Anthem Medicaid	$24.30
Rate for Payer: Anthem POS/PPO/Traditional	$55.12
Rate for Payer: Cash Price	$35.34
Rate for Payer: Cigna Commercial	$58.66
Rate for Payer: First Health Commercial	$67.14
Rate for Payer: Humana Commercial	$60.07
Rate for Payer: Humana KY Medicaid	$24.30
Rate for Payer: Kentucky WC Medicaid	$24.55
Rate for Payer: Medical Mutual Of Ohio HMO	$57.95
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$52.15
Rate for Payer: Molina Healthcare Benefit Exchange	$21.20
Rate for Payer: Molina Healthcare Medicaid	$24.79
Rate for Payer: Ohio Health Choice Commercial	$62.19
Rate for Payer: Ohio Health Group HMO	$53.00
Rate for Payer: Ohio Health Group PPO Differential	$56.54
Rate for Payer: Ohio Health Group PPO No Differential	$61.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$48.76
Rate for Payer: PHCS Commercial	$67.84
Rate for Payer: United Healthcare All Payer	$62.19

PROZAC WEEKLY 90MG CAPSULE DR

Facility

$70.67

Service Code	NDC 55111028448
Hospital Charge Code	25001274
Hospital Revenue Code	637
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$67.84
Rate for Payer: Aetna Commercial	$54.42
Rate for Payer: Anthem POS/PPO/Traditional	$55.12
Rate for Payer: Cash Price	$35.34
Rate for Payer: Cigna Commercial	$58.66
Rate for Payer: First Health Commercial	$67.14
Rate for Payer: Humana Commercial	$60.07
Rate for Payer: Medical Mutual Of Ohio HMO	$57.95
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$52.15
Rate for Payer: Molina Healthcare Benefit Exchange	$21.20
Rate for Payer: Ohio Health Choice Commercial	$62.19
Rate for Payer: Ohio Health Group HMO	$53.00
Rate for Payer: Ohio Health Group PPO Differential	$56.54
Rate for Payer: Ohio Health Group PPO No Differential	$61.48
Rate for Payer: Ohio Health Group PPO SOMC Employees	$48.76
Rate for Payer: PHCS Commercial	$67.84
Rate for Payer: United Healthcare All Payer	$62.19

PRP ADD ON

Professional

Both

$400.00

Hospital Charge Code	22200747
Hospital Revenue Code	222
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Multiplan PHCS	$240.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$280.00
Rate for Payer: UHCCP Medicaid	$140.00

PRP ADD ON PP#1 50%

Professional

Both

$510.00

Hospital Charge Code	22200748
Hospital Revenue Code	222
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$357.00
Rate for Payer: Cash Price	$255.00
Rate for Payer: Multiplan PHCS	$306.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$357.00
Rate for Payer: UHCCP Medicaid	$178.50

PRP ADD ON PP#2/3 25%

Professional

Both

$255.00

Hospital Charge Code	22200749
Hospital Revenue Code	222
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$178.50
Rate for Payer: Cash Price	$127.50
Rate for Payer: Multiplan PHCS	$153.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$178.50
Rate for Payer: UHCCP Medicaid	$89.25

PRP HAIRLOSS-PARTIAL PP#1 50%

Professional

Both

$702.00

Hospital Charge Code	22200754
Hospital Revenue Code	222
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$491.40
Rate for Payer: Cash Price	$351.00
Rate for Payer: Multiplan PHCS	$421.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$491.40
Rate for Payer: UHCCP Medicaid	$245.70

PRP HAIRLOSSPARTIAL PP#2/3 25%

Professional

Both

$350.00

Hospital Charge Code	22200755
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

PRP HAIR LOSS TX -FULL HEAD

Professional

Both

$850.00

Hospital Charge Code	22200750
Hospital Revenue Code	222
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$595.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Multiplan PHCS	$510.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$595.00
Rate for Payer: UHCCP Medicaid	$297.50

PRP HAIR LOSS TX-FULL PP#1 50%

Professional

Both

$1,084.00

Hospital Charge Code	22200751
Hospital Revenue Code	222
Min. Negotiated Rate	$379.40
Max. Negotiated Rate	$758.80
Rate for Payer: Cash Price	$542.00
Rate for Payer: Multiplan PHCS	$650.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$758.80
Rate for Payer: UHCCP Medicaid	$379.40

PRP HAIR LOSSTX-FULLPP#2/3 25%

Professional

Both

$542.00

Hospital Charge Code	22200752
Hospital Revenue Code	222
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$379.40
Rate for Payer: Cash Price	$271.00
Rate for Payer: Multiplan PHCS	$325.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$379.40
Rate for Payer: UHCCP Medicaid	$189.70

PRP HAIR LOSS TX-MAINT

Professional

Both

$600.00

Hospital Charge Code	22200756
Hospital Revenue Code	222
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$420.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Multiplan PHCS	$360.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$420.00
Rate for Payer: UHCCP Medicaid	$210.00

PRP HAIRLOSS TX-MAINT PP#1 50%

Professional

Both

$765.00

Hospital Charge Code	22200757
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

PRP HAIRLOSSTX-MNT PP#2/3 25%

Professional

Both

$383.00

Hospital Charge Code	22200758
Hospital Revenue Code	222
Min. Negotiated Rate	$134.05
Max. Negotiated Rate	$268.10
Rate for Payer: Cash Price	$191.50
Rate for Payer: Multiplan PHCS	$229.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$268.10
Rate for Payer: UHCCP Medicaid	$134.05

PRP HAIR LOSS TX-PARTIAL HEAD

Professional

Both

$550.00

Hospital Charge Code	22200753
Hospital Revenue Code	222
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$385.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Multiplan PHCS	$330.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$385.00
Rate for Payer: UHCCP Medicaid	$192.50

PRP HAIR LOSS TX-SINGLE

Professional

Both

$700.00

Hospital Charge Code	22200759
Hospital Revenue Code	222
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$490.00
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

PRP HAIRLOSS TX-SNG PP#1 50%

Professional

Both

$893.00

Hospital Charge Code	22200760
Hospital Revenue Code	222
Min. Negotiated Rate	$312.55
Max. Negotiated Rate	$625.10
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

PRP HAIRLOSS TX-SNG PP#2/3 25%

Professional

Both

$446.00

Hospital Charge Code	22200761
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

PRQ CARD ANGIO/ATHRECT 1 AR(P

Professional

Both

$1,200.00

Service Code	HCPCS 92924
Hospital Charge Code	761P2455
Hospital Revenue Code	761
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,149.05
Rate for Payer: Ambetter Exchange	$587.89
Rate for Payer: Anthem Medicaid	$517.11
Rate for Payer: Buckeye Individual/Medicaid	$587.89
Rate for Payer: Buckeye Medicare Advantage	$587.89
Rate for Payer: CareSource Just4Me Medicare	$705.47
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cigna Commercial	$1,149.05
Rate for Payer: Healthspan PPO	$761.26
Rate for Payer: Humana Medicaid	$517.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$821.00
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$587.89
Rate for Payer: Molina Healthcare Benefit Exchange	$587.89
Rate for Payer: Molina Healthcare CHIP/Medicaid	$527.45
Rate for Payer: Molina Healthcare Passport	$517.11
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$764.26
Rate for Payer: UHCCP Medicaid	$420.00
Rate for Payer: Wellcare CHIP/Medicaid	$522.28
Rate for Payer: Wellcare Medicare Advantage	$587.89

PRQ CARD ANGIO/ATHRECT 1 AR(T

Facility

$21,101.13

Service Code	HCPCS 92924
Hospital Charge Code	761T2455
Hospital Revenue Code	761
Min. Negotiated Rate	$6,330.34
Max. Negotiated Rate	$20,257.08
Rate for Payer: Aetna Commercial	$16,247.87
Rate for Payer: Anthem POS/PPO/Traditional	$16,458.88
Rate for Payer: Cash Price	$10,550.57
Rate for Payer: Cigna Commercial	$17,513.94
Rate for Payer: First Health Commercial	$20,046.07
Rate for Payer: Humana Commercial	$17,935.96
Rate for Payer: Medical Mutual Of Ohio HMO	$17,302.93
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,572.63
Rate for Payer: Molina Healthcare Benefit Exchange	$6,330.34
Rate for Payer: Ohio Health Choice Commercial	$18,568.99
Rate for Payer: Ohio Health Group HMO	$15,825.85
Rate for Payer: Ohio Health Group PPO Differential	$16,880.90
Rate for Payer: Ohio Health Group PPO No Differential	$18,357.98
Rate for Payer: Ohio Health Group PPO SOMC Employees	$14,559.78
Rate for Payer: PHCS Commercial	$20,257.08
Rate for Payer: United Healthcare All Payer	$18,568.99

PRQ CARD ANGIO/ATHRECT 1 AR(T

Facility

$21,101.13

Service Code	HCPCS 92924
Hospital Charge Code	761T2455
Hospital Revenue Code	761
Min. Negotiated Rate	$7,256.68
Max. Negotiated Rate	$20,257.08
Rate for Payer: Aetna Commercial	$16,247.87
Rate for Payer: Anthem Medicaid	$7,256.68
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Anthem POS/PPO/Traditional	$16,458.88
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Cash Price	$10,550.57
Rate for Payer: Cash Price	$10,550.57
Rate for Payer: Cigna Commercial	$17,513.94
Rate for Payer: First Health Commercial	$20,046.07
Rate for Payer: Humana Commercial	$17,935.96
Rate for Payer: Humana KY Medicaid	$7,256.68
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Kentucky WC Medicaid	$7,330.53
Rate for Payer: Medical Mutual Of Ohio HMO	$17,302.93
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$15,572.63
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15
Rate for Payer: Molina Healthcare Medicaid	$7,402.28
Rate for Payer: Ohio Health Choice Commercial	$18,568.99
Rate for Payer: Ohio Health Group HMO	$15,825.85
Rate for Payer: Ohio Health Group PPO Differential	$16,880.90
Rate for Payer: Ohio Health Group PPO No Differential	$18,357.98
Rate for Payer: Ohio Health Group PPO SOMC Employees	$14,559.78
Rate for Payer: PHCS Commercial	$20,257.08
Rate for Payer: United Healthcare All Payer	$18,568.99

PRQ CARD ANGIO/ATHRECT 1 ART

Facility

$17,051.00

Service Code	HCPCS 92924
Hospital Charge Code	48100046
Hospital Revenue Code	481
Min. Negotiated Rate	$5,863.84
Max. Negotiated Rate	$16,368.96
Rate for Payer: Aetna Commercial	$13,129.27
Rate for Payer: Anthem Medicaid	$5,863.84
Rate for Payer: Anthem Medicare Advantage/PPO	$10,478.46
Rate for Payer: Anthem POS/PPO/Traditional	$13,299.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,669.84
Rate for Payer: CareSource Just4Me Medicare	$14,145.92
Rate for Payer: Cash Price	$8,525.50
Rate for Payer: Cash Price	$8,525.50
Rate for Payer: Cigna Commercial	$14,152.33
Rate for Payer: First Health Commercial	$16,198.45
Rate for Payer: Humana Commercial	$14,493.35
Rate for Payer: Humana KY Medicaid	$5,863.84
Rate for Payer: Humana Medicare Advantage	$10,478.46
Rate for Payer: Kentucky WC Medicaid	$5,923.52
Rate for Payer: Medical Mutual Of Ohio HMO	$13,981.82
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,583.64
Rate for Payer: Molina Healthcare Benefit Exchange	$12,574.15
Rate for Payer: Molina Healthcare Medicaid	$5,981.49
Rate for Payer: Ohio Health Choice Commercial	$15,004.88
Rate for Payer: Ohio Health Group HMO	$12,788.25
Rate for Payer: Ohio Health Group PPO Differential	$13,640.80
Rate for Payer: Ohio Health Group PPO No Differential	$14,834.37
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,765.19
Rate for Payer: PHCS Commercial	$16,368.96
Rate for Payer: United Healthcare All Payer	$15,004.88

PRQ CARD ANGIO/ATHRECT 1 ART

Facility

$17,051.00

Service Code	HCPCS 92924
Hospital Charge Code	48100046
Hospital Revenue Code	481
Min. Negotiated Rate	$5,115.30
Max. Negotiated Rate	$16,368.96
Rate for Payer: Aetna Commercial	$13,129.27
Rate for Payer: Anthem POS/PPO/Traditional	$13,299.78
Rate for Payer: Cash Price	$8,525.50
Rate for Payer: Cigna Commercial	$14,152.33
Rate for Payer: First Health Commercial	$16,198.45
Rate for Payer: Humana Commercial	$14,493.35
Rate for Payer: Medical Mutual Of Ohio HMO	$13,981.82
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$12,583.64
Rate for Payer: Molina Healthcare Benefit Exchange	$5,115.30
Rate for Payer: Ohio Health Choice Commercial	$15,004.88
Rate for Payer: Ohio Health Group HMO	$12,788.25
Rate for Payer: Ohio Health Group PPO Differential	$13,640.80
Rate for Payer: Ohio Health Group PPO No Differential	$14,834.37
Rate for Payer: Ohio Health Group PPO SOMC Employees	$11,765.19
Rate for Payer: PHCS Commercial	$16,368.96
Rate for Payer: United Healthcare All Payer	$15,004.88

Know your out-of-pocket cost for care.

All Charges