Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

SKINPEN-FACE

Professional

Both

$450.00

Hospital Charge Code	22200762
Hospital Revenue Code	222
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$315.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Multiplan PHCS	$270.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$315.00
Rate for Payer: UHCCP Medicaid	$157.50

SKINPEN-FACE/NECK

Professional

Both

$750.00

Hospital Charge Code	22200768
Hospital Revenue Code	222
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$525.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Multiplan PHCS	$450.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$525.00
Rate for Payer: UHCCP Medicaid	$262.50

SKINPEN-FACE/NECK PP#1 50%

Professional

Both

$956.00

Hospital Charge Code	22200769
Hospital Revenue Code	222
Min. Negotiated Rate	$334.60
Max. Negotiated Rate	$669.20
Rate for Payer: Cash Price	$478.00
Rate for Payer: Multiplan PHCS	$573.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$669.20
Rate for Payer: UHCCP Medicaid	$334.60

SKINPEN-FACE/NECK PP#2/3 25%

Professional

Both

$478.00

Hospital Charge Code	22200770
Hospital Revenue Code	222
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$334.60
Rate for Payer: Cash Price	$239.00
Rate for Payer: Multiplan PHCS	$286.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$334.60
Rate for Payer: UHCCP Medicaid	$167.30

SKINPEN-FACE PP#1 50%

Professional

Both

$574.00

Hospital Charge Code	22200763
Hospital Revenue Code	222
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$401.80
Rate for Payer: Cash Price	$287.00
Rate for Payer: Multiplan PHCS	$344.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$401.80
Rate for Payer: UHCCP Medicaid	$200.90

SKINPEN-FACE PP#2/3 25%

Professional

Both

$287.00

Hospital Charge Code	22200764
Hospital Revenue Code	222
Min. Negotiated Rate	$100.45
Max. Negotiated Rate	$200.90
Rate for Payer: Cash Price	$143.50
Rate for Payer: Multiplan PHCS	$172.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$200.90
Rate for Payer: UHCCP Medicaid	$100.45

SKINPEN-NECK

Professional

Both

$350.00

Hospital Charge Code	22200765
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

SKINPEN-NECK PP#1 50%

Professional

Both

$446.00

Hospital Charge Code	22200766
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

SKINPEN-NECK PP#2/3 25%

Professional

Both

$223.00

Hospital Charge Code	22200767
Hospital Revenue Code	222
Min. Negotiated Rate	$78.05
Max. Negotiated Rate	$156.10
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

SKIN SUB GRAFT FACE/NK/HF/G

Facility

$3,477.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$1,195.74
Max. Negotiated Rate	$3,337.92
Rate for Payer: Aetna Commercial	$2,677.29
Rate for Payer: Anthem Medicaid	$1,195.74
Rate for Payer: Anthem Medicare Advantage/PPO	$1,690.17
Rate for Payer: Anthem POS/PPO/Traditional	$2,712.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,366.24
Rate for Payer: CareSource Just4Me Medicare	$2,281.73
Rate for Payer: Cash Price	$1,738.50
Rate for Payer: Cash Price	$1,738.50
Rate for Payer: Cigna Commercial	$2,885.91
Rate for Payer: First Health Commercial	$3,303.15
Rate for Payer: Humana Commercial	$2,955.45
Rate for Payer: Humana KY Medicaid	$1,195.74
Rate for Payer: Humana Medicare Advantage	$1,690.17
Rate for Payer: Kentucky WC Medicaid	$1,207.91
Rate for Payer: Medical Mutual Of Ohio HMO	$2,851.14
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,566.03
Rate for Payer: Molina Healthcare Benefit Exchange	$2,028.20
Rate for Payer: Molina Healthcare Medicaid	$1,219.73
Rate for Payer: Ohio Health Choice Commercial	$3,059.76
Rate for Payer: Ohio Health Group HMO	$2,607.75
Rate for Payer: Ohio Health Group PPO Differential	$2,781.60
Rate for Payer: Ohio Health Group PPO No Differential	$3,024.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,399.13
Rate for Payer: PHCS Commercial	$3,337.92
Rate for Payer: United Healthcare All Payer	$3,059.76

SKIN SUB GRAFT FACE/NK/HF/G

Professional

Both

$3,477.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$47.41
Max. Negotiated Rate	$2,086.20
Rate for Payer: Ambetter Exchange	$88.49
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$47.41
Rate for Payer: Anthem Medicaid	$121.92
Rate for Payer: Buckeye Individual/Medicaid	$88.49
Rate for Payer: Buckeye Medicare Advantage	$88.49
Rate for Payer: CareSource Just4Me Medicare	$106.19
Rate for Payer: Cash Price	$1,738.50
Rate for Payer: Cash Price	$1,738.50
Rate for Payer: Cigna Commercial	$172.63
Rate for Payer: Healthspan PPO	$140.36
Rate for Payer: Humana Medicaid	$121.92
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$127.51
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$88.49
Rate for Payer: Molina Healthcare Benefit Exchange	$88.49
Rate for Payer: Molina Healthcare CHIP/Medicaid	$124.36
Rate for Payer: Molina Healthcare Passport	$121.92
Rate for Payer: Multiplan PHCS	$2,086.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$115.04
Rate for Payer: UHCCP Medicaid	$49.78
Rate for Payer: Wellcare CHIP/Medicaid	$123.14
Rate for Payer: Wellcare Medicare Advantage	$88.49

SKIN SUB GRAFT FACE/NK/HF/G

Facility

$3,477.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$1,043.10
Max. Negotiated Rate	$3,337.92
Rate for Payer: Aetna Commercial	$2,677.29
Rate for Payer: Anthem POS/PPO/Traditional	$2,712.06
Rate for Payer: Cash Price	$1,738.50
Rate for Payer: Cigna Commercial	$2,885.91
Rate for Payer: First Health Commercial	$3,303.15
Rate for Payer: Humana Commercial	$2,955.45
Rate for Payer: Medical Mutual Of Ohio HMO	$2,851.14
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,566.03
Rate for Payer: Molina Healthcare Benefit Exchange	$1,043.10
Rate for Payer: Ohio Health Choice Commercial	$3,059.76
Rate for Payer: Ohio Health Group HMO	$2,607.75
Rate for Payer: Ohio Health Group PPO Differential	$2,781.60
Rate for Payer: Ohio Health Group PPO No Differential	$3,024.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,399.13
Rate for Payer: PHCS Commercial	$3,337.92
Rate for Payer: United Healthcare All Payer	$3,059.76

SKIN SUB GRAFT FACE/NK/HF/G(P

Professional

Both

$100.00

Service Code	HCPCS 15275
Hospital Charge Code	761P0194
Hospital Revenue Code	761
Min. Negotiated Rate	$47.41
Max. Negotiated Rate	$172.63
Rate for Payer: Ambetter Exchange	$88.49
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$47.41
Rate for Payer: Anthem Medicaid	$121.92
Rate for Payer: Buckeye Individual/Medicaid	$88.49
Rate for Payer: Buckeye Medicare Advantage	$88.49
Rate for Payer: CareSource Just4Me Medicare	$106.19
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cigna Commercial	$172.63
Rate for Payer: Healthspan PPO	$140.36
Rate for Payer: Humana Medicaid	$121.92
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$127.51
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$88.49
Rate for Payer: Molina Healthcare Benefit Exchange	$88.49
Rate for Payer: Molina Healthcare CHIP/Medicaid	$124.36
Rate for Payer: Molina Healthcare Passport	$121.92
Rate for Payer: Multiplan PHCS	$60.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$115.04
Rate for Payer: UHCCP Medicaid	$49.78
Rate for Payer: Wellcare CHIP/Medicaid	$123.14
Rate for Payer: Wellcare Medicare Advantage	$88.49

SKIN SUB GRAFT FACE/NK/HF/G(T

Facility

$3,377.00

Service Code	HCPCS 15275
Hospital Charge Code	761T0194
Hospital Revenue Code	761
Min. Negotiated Rate	$1,013.10
Max. Negotiated Rate	$3,241.92
Rate for Payer: Aetna Commercial	$2,600.29
Rate for Payer: Anthem POS/PPO/Traditional	$2,634.06
Rate for Payer: Cash Price	$1,688.50
Rate for Payer: Cigna Commercial	$2,802.91
Rate for Payer: First Health Commercial	$3,208.15
Rate for Payer: Humana Commercial	$2,870.45
Rate for Payer: Medical Mutual Of Ohio HMO	$2,769.14
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,492.23
Rate for Payer: Molina Healthcare Benefit Exchange	$1,013.10
Rate for Payer: Ohio Health Choice Commercial	$2,971.76
Rate for Payer: Ohio Health Group HMO	$2,532.75
Rate for Payer: Ohio Health Group PPO Differential	$2,701.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,937.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,330.13
Rate for Payer: PHCS Commercial	$3,241.92
Rate for Payer: United Healthcare All Payer	$2,971.76

SKIN SUB GRAFT FACE/NK/HF/G(T

Facility

$3,377.00

Service Code	HCPCS 15275
Hospital Charge Code	761T0194
Hospital Revenue Code	761
Min. Negotiated Rate	$1,161.35
Max. Negotiated Rate	$3,241.92
Rate for Payer: Aetna Commercial	$2,600.29
Rate for Payer: Anthem Medicaid	$1,161.35
Rate for Payer: Anthem Medicare Advantage/PPO	$1,690.17
Rate for Payer: Anthem POS/PPO/Traditional	$2,634.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,366.24
Rate for Payer: CareSource Just4Me Medicare	$2,281.73
Rate for Payer: Cash Price	$1,688.50
Rate for Payer: Cash Price	$1,688.50
Rate for Payer: Cigna Commercial	$2,802.91
Rate for Payer: First Health Commercial	$3,208.15
Rate for Payer: Humana Commercial	$2,870.45
Rate for Payer: Humana KY Medicaid	$1,161.35
Rate for Payer: Humana Medicare Advantage	$1,690.17
Rate for Payer: Kentucky WC Medicaid	$1,173.17
Rate for Payer: Medical Mutual Of Ohio HMO	$2,769.14
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,492.23
Rate for Payer: Molina Healthcare Benefit Exchange	$2,028.20
Rate for Payer: Molina Healthcare Medicaid	$1,184.65
Rate for Payer: Ohio Health Choice Commercial	$2,971.76
Rate for Payer: Ohio Health Group HMO	$2,532.75
Rate for Payer: Ohio Health Group PPO Differential	$2,701.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,937.99
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,330.13
Rate for Payer: PHCS Commercial	$3,241.92
Rate for Payer: United Healthcare All Payer	$2,971.76

SKIN SUB GRAFT F/N/HF/G ADDL

Facility

$452.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$135.60
Max. Negotiated Rate	$433.92
Rate for Payer: Aetna Commercial	$348.04
Rate for Payer: Anthem Medicaid	$155.44
Rate for Payer: Anthem POS/PPO/Traditional	$352.56
Rate for Payer: Cash Price	$226.00
Rate for Payer: Cigna Commercial	$375.16
Rate for Payer: First Health Commercial	$429.40
Rate for Payer: Humana Commercial	$384.20
Rate for Payer: Humana KY Medicaid	$155.44
Rate for Payer: Kentucky WC Medicaid	$157.02
Rate for Payer: Medical Mutual Of Ohio HMO	$370.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$333.58
Rate for Payer: Molina Healthcare Benefit Exchange	$135.60
Rate for Payer: Molina Healthcare Medicaid	$158.56
Rate for Payer: Ohio Health Choice Commercial	$397.76
Rate for Payer: Ohio Health Group HMO	$339.00
Rate for Payer: Ohio Health Group PPO Differential	$361.60
Rate for Payer: Ohio Health Group PPO No Differential	$393.24
Rate for Payer: Ohio Health Group PPO SOMC Employees	$311.88
Rate for Payer: PHCS Commercial	$433.92
Rate for Payer: United Healthcare All Payer	$397.76

SKIN SUB GRAFT F/N/HF/G ADDL

Facility

$452.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$135.60
Max. Negotiated Rate	$433.92
Rate for Payer: Aetna Commercial	$348.04
Rate for Payer: Anthem POS/PPO/Traditional	$352.56
Rate for Payer: Cash Price	$226.00
Rate for Payer: Cigna Commercial	$375.16
Rate for Payer: First Health Commercial	$429.40
Rate for Payer: Humana Commercial	$384.20
Rate for Payer: Medical Mutual Of Ohio HMO	$370.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$333.58
Rate for Payer: Molina Healthcare Benefit Exchange	$135.60
Rate for Payer: Ohio Health Choice Commercial	$397.76
Rate for Payer: Ohio Health Group HMO	$339.00
Rate for Payer: Ohio Health Group PPO Differential	$361.60
Rate for Payer: Ohio Health Group PPO No Differential	$393.24
Rate for Payer: Ohio Health Group PPO SOMC Employees	$311.88
Rate for Payer: PHCS Commercial	$433.92
Rate for Payer: United Healthcare All Payer	$397.76

SKIN SUB GRAFT F/N/HF/G ADDL

Professional

Both

$452.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$271.20
Rate for Payer: Ambetter Exchange	$23.48
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$12.98
Rate for Payer: Anthem Medicaid	$26.86
Rate for Payer: Buckeye Individual/Medicaid	$23.48
Rate for Payer: Buckeye Medicare Advantage	$23.48
Rate for Payer: CareSource Just4Me Medicare	$28.18
Rate for Payer: Cash Price	$226.00
Rate for Payer: Cash Price	$226.00
Rate for Payer: Cigna Commercial	$42.32
Rate for Payer: Healthspan PPO	$30.69
Rate for Payer: Humana Medicaid	$26.86
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.08
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$23.48
Rate for Payer: Molina Healthcare Benefit Exchange	$23.48
Rate for Payer: Molina Healthcare CHIP/Medicaid	$27.40
Rate for Payer: Molina Healthcare Passport	$26.86
Rate for Payer: Multiplan PHCS	$271.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$30.52
Rate for Payer: UHCCP Medicaid	$13.63
Rate for Payer: Wellcare CHIP/Medicaid	$27.13
Rate for Payer: Wellcare Medicare Advantage	$23.48

SKIN SUB GRAFT F/N/HF/G ADD(P

Professional

Both

$265.00

Service Code	HCPCS 15276
Hospital Charge Code	761P0195
Hospital Revenue Code	761
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$159.00
Rate for Payer: Ambetter Exchange	$23.48
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$12.98
Rate for Payer: Anthem Medicaid	$26.86
Rate for Payer: Buckeye Individual/Medicaid	$23.48
Rate for Payer: Buckeye Medicare Advantage	$23.48
Rate for Payer: CareSource Just4Me Medicare	$28.18
Rate for Payer: Cash Price	$132.50
Rate for Payer: Cash Price	$132.50
Rate for Payer: Cigna Commercial	$42.32
Rate for Payer: Healthspan PPO	$30.69
Rate for Payer: Humana Medicaid	$26.86
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.08
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$23.48
Rate for Payer: Molina Healthcare Benefit Exchange	$23.48
Rate for Payer: Molina Healthcare CHIP/Medicaid	$27.40
Rate for Payer: Molina Healthcare Passport	$26.86
Rate for Payer: Multiplan PHCS	$159.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$30.52
Rate for Payer: UHCCP Medicaid	$13.63
Rate for Payer: Wellcare CHIP/Medicaid	$27.13
Rate for Payer: Wellcare Medicare Advantage	$23.48

SKIN SUB GRAFT F/N/HF/G ADD(T

Facility

$187.00

Service Code	HCPCS 15276
Hospital Charge Code	761T0195
Hospital Revenue Code	761
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$179.52
Rate for Payer: Aetna Commercial	$143.99
Rate for Payer: Anthem Medicaid	$64.31
Rate for Payer: Anthem POS/PPO/Traditional	$145.86
Rate for Payer: Cash Price	$93.50
Rate for Payer: Cigna Commercial	$155.21
Rate for Payer: First Health Commercial	$177.65
Rate for Payer: Humana Commercial	$158.95
Rate for Payer: Humana KY Medicaid	$64.31
Rate for Payer: Kentucky WC Medicaid	$64.96
Rate for Payer: Medical Mutual Of Ohio HMO	$153.34
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$138.01
Rate for Payer: Molina Healthcare Benefit Exchange	$56.10
Rate for Payer: Molina Healthcare Medicaid	$65.60
Rate for Payer: Ohio Health Choice Commercial	$164.56
Rate for Payer: Ohio Health Group HMO	$140.25
Rate for Payer: Ohio Health Group PPO Differential	$149.60
Rate for Payer: Ohio Health Group PPO No Differential	$162.69
Rate for Payer: Ohio Health Group PPO SOMC Employees	$129.03
Rate for Payer: PHCS Commercial	$179.52
Rate for Payer: United Healthcare All Payer	$164.56

SKIN SUB GRAFT F/N/HF/G ADD(T

Facility

$187.00

Service Code	HCPCS 15276
Hospital Charge Code	761T0195
Hospital Revenue Code	761
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$179.52
Rate for Payer: Aetna Commercial	$143.99
Rate for Payer: Anthem POS/PPO/Traditional	$145.86
Rate for Payer: Cash Price	$93.50
Rate for Payer: Cigna Commercial	$155.21
Rate for Payer: First Health Commercial	$177.65
Rate for Payer: Humana Commercial	$158.95
Rate for Payer: Medical Mutual Of Ohio HMO	$153.34
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$138.01
Rate for Payer: Molina Healthcare Benefit Exchange	$56.10
Rate for Payer: Ohio Health Choice Commercial	$164.56
Rate for Payer: Ohio Health Group HMO	$140.25
Rate for Payer: Ohio Health Group PPO Differential	$149.60
Rate for Payer: Ohio Health Group PPO No Differential	$162.69
Rate for Payer: Ohio Health Group PPO SOMC Employees	$129.03
Rate for Payer: PHCS Commercial	$179.52
Rate for Payer: United Healthcare All Payer	$164.56

SKIN TEST CANDIDA

Facility

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$17.94
Max. Negotiated Rate	$31.68
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Anthem Medicaid	$22.63
Rate for Payer: Anthem Medicare Advantage/PPO	$22.63
Rate for Payer: Anthem POS/PPO/Traditional	$20.88
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$31.68
Rate for Payer: CareSource Just4Me Medicare	$22.63
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$21.58
Rate for Payer: First Health Commercial	$24.70
Rate for Payer: Humana Commercial	$22.10
Rate for Payer: Humana KY Medicaid	$22.63
Rate for Payer: Humana Medicare Advantage	$22.63
Rate for Payer: Kentucky WC Medicaid	$22.86
Rate for Payer: Medical Mutual Of Ohio HMO	$21.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$19.19
Rate for Payer: Molina Healthcare Benefit Exchange	$27.16
Rate for Payer: Molina Healthcare Medicaid	$23.08
Rate for Payer: Ohio Health Choice Commercial	$22.88
Rate for Payer: Ohio Health Group HMO	$19.50
Rate for Payer: Ohio Health Group PPO Differential	$20.80
Rate for Payer: Ohio Health Group PPO No Differential	$22.62
Rate for Payer: Ohio Health Group PPO SOMC Employees	$17.94
Rate for Payer: PHCS Commercial	$24.96
Rate for Payer: United Healthcare All Payer	$22.88

SKIN TEST CANDIDA

Facility

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$24.96
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Anthem POS/PPO/Traditional	$20.88
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$21.58
Rate for Payer: First Health Commercial	$24.70
Rate for Payer: Humana Commercial	$22.10
Rate for Payer: Medical Mutual Of Ohio HMO	$21.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$19.19
Rate for Payer: Molina Healthcare Benefit Exchange	$7.80
Rate for Payer: Ohio Health Choice Commercial	$22.88
Rate for Payer: Ohio Health Group HMO	$19.50
Rate for Payer: Ohio Health Group PPO Differential	$20.80
Rate for Payer: Ohio Health Group PPO No Differential	$22.62
Rate for Payer: Ohio Health Group PPO SOMC Employees	$17.94
Rate for Payer: PHCS Commercial	$24.96
Rate for Payer: United Healthcare All Payer	$22.88

SKIN TEST CANDIDA

Professional

Both

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$19.49
Rate for Payer: Aetna Commercial	$17.66
Rate for Payer: Anthem Medicaid	$5.68
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$13.80
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$5.68
Rate for Payer: Molina Healthcare CHIP/Medicaid	$5.79
Rate for Payer: Molina Healthcare Passport	$5.68
Rate for Payer: Multiplan PHCS	$15.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$18.20
Rate for Payer: UHCCP Medicaid	$9.10
Rate for Payer: Wellcare CHIP/Medicaid	$19.49

SKIN TEST- TB -INTRADERMAL

Facility

$25.00

Service Code	HCPCS 86580
Hospital Charge Code	30001103
Hospital Revenue Code	302
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$19.25
Rate for Payer: Anthem POS/PPO/Traditional	$20.07
Rate for Payer: Cash Price	$12.50
Rate for Payer: Cigna Commercial	$20.75
Rate for Payer: First Health Commercial	$23.75
Rate for Payer: Humana Commercial	$21.25
Rate for Payer: Medical Mutual Of Ohio HMO	$20.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$18.45
Rate for Payer: Molina Healthcare Benefit Exchange	$7.50
Rate for Payer: Ohio Health Choice Commercial	$22.00
Rate for Payer: Ohio Health Group HMO	$18.75
Rate for Payer: Ohio Health Group PPO Differential	$20.00
Rate for Payer: Ohio Health Group PPO No Differential	$21.75
Rate for Payer: Ohio Health Group PPO SOMC Employees	$17.25
Rate for Payer: PHCS Commercial	$24.00
Rate for Payer: United Healthcare All Payer	$22.00

Know your out-of-pocket cost for care.

All Charges