Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

TRL Deep Cheek -PP #2/3 25%

Professional

Both

$892.00

Hospital Charge Code	22200514
Hospital Revenue Code	222
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$892.00
Rate for Payer: Buckeye Medicare Advantage	$892.00
Rate for Payer: Cash Price	$446.00
Rate for Payer: Multiplan PHCS	$535.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$624.40
Rate for Payer: UHCCP Medicaid	$312.20

TRL DEEP CHEEKS

Professional

Both

$1,400.00

Hospital Charge Code	22200298
Hospital Revenue Code	222
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$1,400.00
Rate for Payer: Buckeye Medicare Advantage	$1,400.00
Rate for Payer: Cash Price	$700.00
Rate for Payer: Multiplan PHCS	$840.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$980.00
Rate for Payer: UHCCP Medicaid	$490.00

TRL Deep Cheeks -PP #1 50%

Professional

Both

$1,786.00

Hospital Charge Code	22200299
Hospital Revenue Code	222
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$1,786.00
Rate for Payer: Buckeye Medicare Advantage	$1,786.00
Rate for Payer: Cash Price	$893.00
Rate for Payer: Multiplan PHCS	$1,071.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,250.20
Rate for Payer: UHCCP Medicaid	$625.10

TRL DEEP EYELIDS

Professional

Both

$1,200.00

Hospital Charge Code	22200296
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Buckeye Medicare Advantage	$1,200.00
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

TRL Deep Eyelids-PP#1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200297
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,530.00
Rate for Payer: Buckeye Medicare Advantage	$1,530.00
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

TRL Deep Eyelids-PP#2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200513
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$765.00
Rate for Payer: Buckeye Medicare Advantage	$765.00
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

TRL DEEP FULL FACE

Professional

Both

$2,900.00

Hospital Charge Code	22200302
Hospital Revenue Code	222
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$2,900.00
Rate for Payer: Buckeye Medicare Advantage	$2,900.00
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

TRL Deep Full Face -PP #1 50%

Professional

Both

$3,699.00

Hospital Charge Code	22200303
Hospital Revenue Code	222
Min. Negotiated Rate	$1,294.65
Max. Negotiated Rate	$3,699.00
Rate for Payer: Buckeye Medicare Advantage	$3,699.00
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

TRL Deep Full Face-PP #2/3 25%

Professional

Both

$1,848.00

Hospital Charge Code	22200516
Hospital Revenue Code	222
Min. Negotiated Rate	$646.80
Max. Negotiated Rate	$1,848.00
Rate for Payer: Buckeye Medicare Advantage	$1,848.00
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

TRL DEEP NECK

Professional

Both

$1,000.00

Hospital Charge Code	22200305
Hospital Revenue Code	222
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$1,000.00
Rate for Payer: Buckeye Medicare Advantage	$1,000.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Multiplan PHCS	$600.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$700.00
Rate for Payer: UHCCP Medicaid	$350.00

TRL Deep Neck - PP #1 50%

Professional

Both

$1,276.00

Hospital Charge Code	22200306
Hospital Revenue Code	222
Min. Negotiated Rate	$446.60
Max. Negotiated Rate	$1,276.00
Rate for Payer: Buckeye Medicare Advantage	$1,276.00
Rate for Payer: Cash Price	$638.00
Rate for Payer: Multiplan PHCS	$765.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$893.20
Rate for Payer: UHCCP Medicaid	$446.60

TRL Deep Neck -PP#2/3 25%

Professional

Both

$637.00

Hospital Charge Code	22200518
Hospital Revenue Code	222
Min. Negotiated Rate	$222.95
Max. Negotiated Rate	$637.00
Rate for Payer: Buckeye Medicare Advantage	$637.00
Rate for Payer: Cash Price	$318.50
Rate for Payer: Multiplan PHCS	$382.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$445.90
Rate for Payer: UHCCP Medicaid	$222.95

TRL DEEP PERIORAL

Professional

Both

$1,200.00

Hospital Charge Code	22200300
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Buckeye Medicare Advantage	$1,200.00
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

TRL Deep Perioral-PP #1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200301
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,530.00
Rate for Payer: Buckeye Medicare Advantage	$1,530.00
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

TRL Deep Perioral-PP#2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200515
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$765.00
Rate for Payer: Buckeye Medicare Advantage	$765.00
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

TRL MicHand-PP #1 50%

Professional

Both

$256.00

Hospital Charge Code	22200295
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

TRL MicHand-PP#2/3 25%

Professional

Both

$127.00

Hospital Charge Code	22200512
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

TRL MicPartl Fce4Area-PP#1 50%

Professional

Both

$510.00

Hospital Charge Code	22200289
Hospital Revenue Code	222
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$510.00
Rate for Payer: Buckeye Medicare Advantage	$510.00
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

TRLMicPartlFce4Area-PP#2/3 25%

Professional

Both

$255.00

Hospital Charge Code	22200509
Hospital Revenue Code	222
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$255.00
Rate for Payer: Buckeye Medicare Advantage	$255.00
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

TRL Micro Hands

Professional

Both

$200.00

Hospital Charge Code	22200294
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

TRL Micro Mod Face

Professional

Both

$500.00

Hospital Charge Code	22200290
Hospital Revenue Code	222
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$500.00
Rate for Payer: Buckeye Medicare Advantage	$500.00
Rate for Payer: Cash Price	$250.00
Rate for Payer: Multiplan PHCS	$300.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$350.00
Rate for Payer: UHCCP Medicaid	$175.00

TRL Micro Mod Face-PP#1 50%

Professional

Both

$639.00

Hospital Charge Code	22200291
Hospital Revenue Code	222
Min. Negotiated Rate	$223.65
Max. Negotiated Rate	$639.00
Rate for Payer: Buckeye Medicare Advantage	$639.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Multiplan PHCS	$383.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$447.30
Rate for Payer: UHCCP Medicaid	$223.65

TRL Micro Mod Face-PP#2/3 25%

Professional

Both

$318.00

Hospital Charge Code	22200510
Hospital Revenue Code	222
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$318.00
Rate for Payer: Buckeye Medicare Advantage	$318.00
Rate for Payer: Cash Price	$159.00
Rate for Payer: Multiplan PHCS	$190.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$222.60
Rate for Payer: UHCCP Medicaid	$111.30

TRL Micro Neck

Professional

Both

$300.00

Hospital Charge Code	22200292
Hospital Revenue Code	222
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$300.00
Rate for Payer: Buckeye Medicare Advantage	$300.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Multiplan PHCS	$180.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$210.00
Rate for Payer: UHCCP Medicaid	$105.00

TRL Micro Neck-PP #1 50%

Professional

Both

$383.00

Hospital Charge Code	22200293
Hospital Revenue Code	222
Min. Negotiated Rate	$134.05
Max. Negotiated Rate	$383.00
Rate for Payer: Buckeye Medicare Advantage	$383.00
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

Know your out-of-pocket cost for care.

All Charges