Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EAPG 882: GENETIC COUNSELING

Facility

$78.86

Service Code	EAPG 00882
Min. Negotiated Rate	$78.86
Max. Negotiated Rate	$78.86
Rate for Payer: Aetna CHP/Medicaid	$78.86
Rate for Payer: Humana OH Medicaid	$78.86

EAPG 883: ALTERATION IN CONSCIOUSNESS

Facility

$104.67

Service Code	EAPG 00883
Min. Negotiated Rate	$104.67
Max. Negotiated Rate	$104.67
Rate for Payer: Aetna CHP/Medicaid	$104.67
Rate for Payer: Humana OH Medicaid	$104.67

EAPG 90: LEVEL I VARICOSE VEIN AND RELATED PROCEDURES

Facility

$349.70

Service Code	EAPG 00090
Min. Negotiated Rate	$349.70
Max. Negotiated Rate	$349.70
Rate for Payer: Aetna CHP/Medicaid	$349.70
Rate for Payer: Humana OH Medicaid	$349.70

EAPG 91: LEVEL II PERIPHERAL VASCULAR REPAIR, LIGATION OR RECONSTRUCTION

Facility

$2,450.19

Service Code	EAPG 00091
Min. Negotiated Rate	$2,450.19
Max. Negotiated Rate	$2,450.19
Rate for Payer: Aetna CHP/Medicaid	$2,450.19
Rate for Payer: Humana OH Medicaid	$2,450.19

EAPG 92: RESUSCITATION

Facility

$529.65

Service Code	EAPG 00092
Min. Negotiated Rate	$529.65
Max. Negotiated Rate	$529.65
Rate for Payer: Aetna CHP/Medicaid	$529.65
Rate for Payer: Humana OH Medicaid	$529.65

EAPG 93: CARDIOVERSION

Facility

$348.01

Service Code	EAPG 00093
Min. Negotiated Rate	$348.01
Max. Negotiated Rate	$348.01
Rate for Payer: Aetna CHP/Medicaid	$348.01
Rate for Payer: Humana OH Medicaid	$348.01

EAPG 94: CARDIAC REHABILITATION

Facility

$60.54

Service Code	EAPG 00094
Min. Negotiated Rate	$60.54
Max. Negotiated Rate	$60.54
Rate for Payer: Aetna CHP/Medicaid	$60.54
Rate for Payer: Humana OH Medicaid	$60.54

EAPG 96: CARDIAC ELECTROPHYSIOLOGIC PROCEDURES INCLUDING PACING AND RECORDING

Facility

$1,365.62

Service Code	EAPG 00096
Min. Negotiated Rate	$1,365.62
Max. Negotiated Rate	$1,365.62
Rate for Payer: Aetna CHP/Medicaid	$1,365.62
Rate for Payer: Humana OH Medicaid	$1,365.62

EAPG 97: AICD AND RELATED CARDIAC DEVICE INSERTION OR REPLACEMENT

Facility

$19,111.64

Service Code	EAPG 00097
Min. Negotiated Rate	$19,111.64
Max. Negotiated Rate	$19,111.64
Rate for Payer: Aetna CHP/Medicaid	$19,111.64
Rate for Payer: Humana OH Medicaid	$19,111.64

EAPG 99: LEVEL I PERCUTANEOUS CORONARY AND INTRACARDIAC INTERVENTIONAL PROCEDURES

Facility

$5,138.93

Service Code	EAPG 00099
Min. Negotiated Rate	$5,138.93
Max. Negotiated Rate	$5,138.93
Rate for Payer: Aetna CHP/Medicaid	$5,138.93
Rate for Payer: Humana OH Medicaid	$5,138.93

EAPG 9: LEVEL I SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility

$340.83

Service Code	EAPG 00009
Min. Negotiated Rate	$340.83
Max. Negotiated Rate	$340.83
Rate for Payer: Aetna CHP/Medicaid	$340.83
Rate for Payer: Humana OH Medicaid	$340.83

EAR CARTILAGE GRAFT

Professional

Both

$8,347.00

Service Code	HCPCS 21235
Hospital Charge Code	76100376
Hospital Revenue Code	761
Min. Negotiated Rate	$300.07
Max. Negotiated Rate	$8,347.00
Rate for Payer: Aetna Commercial	$804.76
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$300.07
Rate for Payer: Anthem Medicaid	$426.41
Rate for Payer: Buckeye Medicare Advantage	$8,347.00
Rate for Payer: Cash Price	$4,173.50
Rate for Payer: Cash Price	$4,173.50
Rate for Payer: Cigna Commercial	$871.52
Rate for Payer: Healthspan PPO	$910.25
Rate for Payer: Humana Medicaid	$426.41
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$711.92
Rate for Payer: Molina Healthcare CHIP/Medicaid	$434.94
Rate for Payer: Molina Healthcare Passport	$426.41
Rate for Payer: Multiplan PHCS	$5,008.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$5,842.90
Rate for Payer: UHCCP Medicaid	$315.07
Rate for Payer: Wellcare CHIP/Medicaid	$430.67

EAR CARTILAGE GRAFT

Facility

$8,347.00

Service Code	HCPCS 21235
Hospital Charge Code	76100376
Hospital Revenue Code	761
Min. Negotiated Rate	$1,085.11
Max. Negotiated Rate	$8,013.12
Rate for Payer: Aetna Commercial	$6,427.19
Rate for Payer: Anthem POS/PPO/Traditional	$6,510.66
Rate for Payer: Cash Price	$4,173.50
Rate for Payer: Cigna Commercial	$6,928.01
Rate for Payer: First Health Commercial	$7,929.65
Rate for Payer: Humana Commercial	$7,094.95
Rate for Payer: Medical Mutual Of Ohio HMO	$6,844.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,160.09
Rate for Payer: Molina Healthcare Benefit Exchange	$2,504.10
Rate for Payer: Ohio Health Choice Commercial	$7,345.36
Rate for Payer: Ohio Health Group HMO	$6,260.25
Rate for Payer: Ohio Health Group PPO Differential	$1,669.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,085.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,587.57
Rate for Payer: PHCS Commercial	$8,013.12
Rate for Payer: United Healthcare All Payer	$7,345.36

EAR CARTILAGE GRAFT

Facility

$8,347.00

Service Code	HCPCS 21235
Hospital Charge Code	76100376
Hospital Revenue Code	761
Min. Negotiated Rate	$1,085.11
Max. Negotiated Rate	$8,013.12
Rate for Payer: Aetna Commercial	$6,427.19
Rate for Payer: Anthem Medicaid	$2,870.53
Rate for Payer: Anthem Medicare Advantage/PPO	$5,064.14
Rate for Payer: Anthem POS/PPO/Traditional	$6,510.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,089.80
Rate for Payer: CareSource Just4Me Medicare	$6,836.59
Rate for Payer: Cash Price	$4,173.50
Rate for Payer: Cash Price	$4,173.50
Rate for Payer: Cigna Commercial	$6,928.01
Rate for Payer: First Health Commercial	$7,929.65
Rate for Payer: Humana Commercial	$7,094.95
Rate for Payer: Humana KY Medicaid	$2,870.53
Rate for Payer: Humana Medicare Advantage	$5,064.14
Rate for Payer: Kentucky WC Medicaid	$2,899.75
Rate for Payer: Medical Mutual Of Ohio HMO	$6,844.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,160.09
Rate for Payer: Molina Healthcare Benefit Exchange	$6,076.97
Rate for Payer: Molina Healthcare Medicaid	$2,928.13
Rate for Payer: Ohio Health Choice Commercial	$7,345.36
Rate for Payer: Ohio Health Group HMO	$6,260.25
Rate for Payer: Ohio Health Group PPO Differential	$1,669.40
Rate for Payer: Ohio Health Group PPO No Differential	$1,085.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,587.57
Rate for Payer: PHCS Commercial	$8,013.12
Rate for Payer: United Healthcare All Payer	$7,345.36

EAR CARTILAGE GRAFT(P

Professional

Both

$1,400.00

Service Code	HCPCS 21235
Hospital Charge Code	761P0376
Hospital Revenue Code	761
Min. Negotiated Rate	$300.07
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$804.76
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$300.07
Rate for Payer: Anthem Medicaid	$426.41
Rate for Payer: Buckeye Medicare Advantage	$1,400.00
Rate for Payer: Cash Price	$700.00
Rate for Payer: Cash Price	$700.00
Rate for Payer: Cigna Commercial	$871.52
Rate for Payer: Healthspan PPO	$910.25
Rate for Payer: Humana Medicaid	$426.41
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$711.92
Rate for Payer: Molina Healthcare CHIP/Medicaid	$434.94
Rate for Payer: Molina Healthcare Passport	$426.41
Rate for Payer: Multiplan PHCS	$840.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$980.00
Rate for Payer: UHCCP Medicaid	$315.07
Rate for Payer: Wellcare CHIP/Medicaid	$430.67

EAR CARTILAGE GRAFT(T

Facility

$6,947.00

Service Code	HCPCS 21235
Hospital Charge Code	761T0376
Hospital Revenue Code	761
Min. Negotiated Rate	$903.11
Max. Negotiated Rate	$7,089.80
Rate for Payer: Aetna Commercial	$5,349.19
Rate for Payer: Anthem Medicaid	$2,389.07
Rate for Payer: Anthem Medicare Advantage/PPO	$5,064.14
Rate for Payer: Anthem POS/PPO/Traditional	$5,418.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,089.80
Rate for Payer: CareSource Just4Me Medicare	$6,836.59
Rate for Payer: Cash Price	$3,473.50
Rate for Payer: Cash Price	$3,473.50
Rate for Payer: Cigna Commercial	$5,766.01
Rate for Payer: First Health Commercial	$6,599.65
Rate for Payer: Humana Commercial	$5,904.95
Rate for Payer: Humana KY Medicaid	$2,389.07
Rate for Payer: Humana Medicare Advantage	$5,064.14
Rate for Payer: Kentucky WC Medicaid	$2,413.39
Rate for Payer: Medical Mutual Of Ohio HMO	$5,696.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,126.89
Rate for Payer: Molina Healthcare Benefit Exchange	$6,076.97
Rate for Payer: Molina Healthcare Medicaid	$2,437.01
Rate for Payer: Ohio Health Choice Commercial	$6,113.36
Rate for Payer: Ohio Health Group HMO	$5,210.25
Rate for Payer: Ohio Health Group PPO Differential	$1,389.40
Rate for Payer: Ohio Health Group PPO No Differential	$903.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,153.57
Rate for Payer: PHCS Commercial	$6,669.12
Rate for Payer: United Healthcare All Payer	$6,113.36

EAR CARTILAGE GRAFT(T

Facility

$6,947.00

Service Code	HCPCS 21235
Hospital Charge Code	761T0376
Hospital Revenue Code	761
Min. Negotiated Rate	$903.11
Max. Negotiated Rate	$6,669.12
Rate for Payer: Aetna Commercial	$5,349.19
Rate for Payer: Anthem POS/PPO/Traditional	$5,418.66
Rate for Payer: Cash Price	$3,473.50
Rate for Payer: Cigna Commercial	$5,766.01
Rate for Payer: First Health Commercial	$6,599.65
Rate for Payer: Humana Commercial	$5,904.95
Rate for Payer: Medical Mutual Of Ohio HMO	$5,696.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,126.89
Rate for Payer: Molina Healthcare Benefit Exchange	$2,084.10
Rate for Payer: Ohio Health Choice Commercial	$6,113.36
Rate for Payer: Ohio Health Group HMO	$5,210.25
Rate for Payer: Ohio Health Group PPO Differential	$1,389.40
Rate for Payer: Ohio Health Group PPO No Differential	$903.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,153.57
Rate for Payer: PHCS Commercial	$6,669.12
Rate for Payer: United Healthcare All Payer	$6,113.36

EAR LOBE REPAIR

Professional

Both

$300.00

Hospital Charge Code	22200019
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

EAR MOLD

Facility

$80.00

Service Code	HCPCS V5264
Hospital Charge Code	47000035
Hospital Revenue Code	470
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem POS/PPO/Traditional	$62.40
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

EAR MOLD

Facility

$80.00

Service Code	HCPCS V5264
Hospital Charge Code	47000035
Hospital Revenue Code	470
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem Medicaid	$27.51
Rate for Payer: Anthem POS/PPO/Traditional	$62.40
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	$27.51
Rate for Payer: Kentucky WC Medicaid	$27.79
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: Molina Healthcare Medicaid	$28.06
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

EAR MOLD(P

Professional

Both

$30.00

Service Code	HCPCS V5264
Hospital Charge Code	470P0035
Hospital Revenue Code	470
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$70.90
Rate for Payer: Aetna Commercial	$59.23
Rate for Payer: Buckeye Medicare Advantage	$30.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$70.90
Rate for Payer: Multiplan PHCS	$18.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$21.00
Rate for Payer: UHCCP Medicaid	$10.50

EAR MOLD SP

Professional

Both

$77.00

Hospital Charge Code	47000102
Hospital Revenue Code	222
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$77.00
Rate for Payer: Buckeye Medicare Advantage	$77.00
Rate for Payer: Cash Price	$38.50
Rate for Payer: Multiplan PHCS	$46.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$53.90
Rate for Payer: UHCCP Medicaid	$26.95

EAR MOLD(T

Facility

$80.00

Service Code	HCPCS V5264
Hospital Charge Code	470T0035
Hospital Revenue Code	470
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem Medicaid	$27.51
Rate for Payer: Anthem POS/PPO/Traditional	$62.40
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	$27.51
Rate for Payer: Kentucky WC Medicaid	$27.79
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: Molina Healthcare Medicaid	$28.06
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

EAR MOLD(T

Facility

$80.00

Service Code	HCPCS V5264
Hospital Charge Code	470T0035
Hospital Revenue Code	470
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna Commercial	$61.60
Rate for Payer: Anthem POS/PPO/Traditional	$62.40
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

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$14,456.62

Service Code	MSDRG 147
Min. Negotiated Rate	$9,809.85
Max. Negotiated Rate	$14,456.62
Rate for Payer: Anthem Medicaid	$9,809.85
Rate for Payer: Anthem Medicare Advantage/PPO	$10,326.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,456.62
Rate for Payer: CareSource Just4Me Medicare	$13,940.32
Rate for Payer: Humana KY Medicaid	$9,809.85
Rate for Payer: Humana Medicare Advantage	$10,326.16
Rate for Payer: Kentucky WC Medicaid	$9,907.95
Rate for Payer: Molina Healthcare Benefit Exchange	$12,391.39
Rate for Payer: Molina Healthcare Medicaid	$10,006.05

Know your out-of-pocket cost for care.

All Charges