Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR HEAD AREA 2.6 TO 7.5 CM

Professional

Both

$800.00

Service Code	HCPCS 13152
Hospital Charge Code	761P0159
Hospital Revenue Code	761
Min. Negotiated Rate	$169.40
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$613.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$169.40
Rate for Payer: Anthem Medicaid	$269.60
Rate for Payer: Buckeye Medicare Advantage	$800.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cigna Commercial	$713.20
Rate for Payer: Healthspan PPO	$624.42
Rate for Payer: Humana Medicaid	$269.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$534.76
Rate for Payer: Molina Healthcare CHIP/Medicaid	$274.99
Rate for Payer: Molina Healthcare Passport	$269.60
Rate for Payer: Multiplan PHCS	$480.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$560.00
Rate for Payer: UHCCP Medicaid	$177.87
Rate for Payer: Wellcare CHIP/Medicaid	$272.30

REPAIR HEAD AREA 2.6 TO 7.5 CM

Facility

$2,547.00

Service Code	HCPCS 13152
Hospital Charge Code	76100159
Hospital Revenue Code	761
Min. Negotiated Rate	$331.11
Max. Negotiated Rate	$2,445.12
Rate for Payer: Aetna Commercial	$1,961.19
Rate for Payer: Anthem POS/PPO/Traditional	$1,986.66
Rate for Payer: Cash Price	$1,273.50
Rate for Payer: Cigna Commercial	$2,114.01
Rate for Payer: First Health Commercial	$2,419.65
Rate for Payer: Humana Commercial	$2,164.95
Rate for Payer: Medical Mutual Of Ohio HMO	$2,088.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,879.69
Rate for Payer: Molina Healthcare Benefit Exchange	$764.10
Rate for Payer: Ohio Health Choice Commercial	$2,241.36
Rate for Payer: Ohio Health Group HMO	$1,910.25
Rate for Payer: Ohio Health Group PPO Differential	$509.40
Rate for Payer: Ohio Health Group PPO No Differential	$331.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$789.57
Rate for Payer: PHCS Commercial	$2,445.12
Rate for Payer: United Healthcare All Payer	$2,241.36

REPAIR HEAD AREA 2.6 TO 7.5 CM

Facility

$1,747.00

Service Code	HCPCS 13152
Hospital Charge Code	45000075
Hospital Revenue Code	450
Min. Negotiated Rate	$227.11
Max. Negotiated Rate	$1,677.12
Rate for Payer: Aetna Commercial	$1,345.19
Rate for Payer: Anthem POS/PPO/Traditional	$1,362.66
Rate for Payer: Cash Price	$873.50
Rate for Payer: Cigna Commercial	$1,450.01
Rate for Payer: First Health Commercial	$1,659.65
Rate for Payer: Humana Commercial	$1,484.95
Rate for Payer: Medical Mutual Of Ohio HMO	$1,432.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,289.29
Rate for Payer: Molina Healthcare Benefit Exchange	$524.10
Rate for Payer: Ohio Health Choice Commercial	$1,537.36
Rate for Payer: Ohio Health Group HMO	$1,310.25
Rate for Payer: Ohio Health Group PPO Differential	$349.40
Rate for Payer: Ohio Health Group PPO No Differential	$227.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$541.57
Rate for Payer: PHCS Commercial	$1,677.12
Rate for Payer: United Healthcare All Payer	$1,537.36

REPAIR HEAD AREA 2.6 TO 7.5 CM

Professional

Both

$2,547.00

Service Code	HCPCS 13152
Hospital Charge Code	76100159
Hospital Revenue Code	761
Min. Negotiated Rate	$169.40
Max. Negotiated Rate	$2,547.00
Rate for Payer: Aetna Commercial	$613.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$169.40
Rate for Payer: Anthem Medicaid	$269.60
Rate for Payer: Buckeye Medicare Advantage	$2,547.00
Rate for Payer: Cash Price	$1,273.50
Rate for Payer: Cash Price	$1,273.50
Rate for Payer: Cigna Commercial	$713.20
Rate for Payer: Healthspan PPO	$624.42
Rate for Payer: Humana Medicaid	$269.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$534.76
Rate for Payer: Molina Healthcare CHIP/Medicaid	$274.99
Rate for Payer: Molina Healthcare Passport	$269.60
Rate for Payer: Multiplan PHCS	$1,528.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,782.90
Rate for Payer: UHCCP Medicaid	$177.87
Rate for Payer: Wellcare CHIP/Medicaid	$272.30

REPAIR HEAD AREA 2.6 TO 7.5 CM

Facility

$2,547.00

Service Code	HCPCS 13152
Hospital Charge Code	76100159
Hospital Revenue Code	761
Min. Negotiated Rate	$331.11
Max. Negotiated Rate	$2,445.12
Rate for Payer: Aetna Commercial	$1,961.19
Rate for Payer: Anthem Medicaid	$875.91
Rate for Payer: Anthem Medicare Advantage/PPO	$543.11
Rate for Payer: Anthem POS/PPO/Traditional	$1,986.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$760.35
Rate for Payer: CareSource Just4Me Medicare	$733.20
Rate for Payer: Cash Price	$1,273.50
Rate for Payer: Cash Price	$1,273.50
Rate for Payer: Cigna Commercial	$2,114.01
Rate for Payer: First Health Commercial	$2,419.65
Rate for Payer: Humana Commercial	$2,164.95
Rate for Payer: Humana KY Medicaid	$875.91
Rate for Payer: Humana Medicare Advantage	$543.11
Rate for Payer: Kentucky WC Medicaid	$884.83
Rate for Payer: Medical Mutual Of Ohio HMO	$2,088.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,879.69
Rate for Payer: Molina Healthcare Benefit Exchange	$651.73
Rate for Payer: Molina Healthcare Medicaid	$893.49
Rate for Payer: Ohio Health Choice Commercial	$2,241.36
Rate for Payer: Ohio Health Group HMO	$1,910.25
Rate for Payer: Ohio Health Group PPO Differential	$509.40
Rate for Payer: Ohio Health Group PPO No Differential	$331.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$789.57
Rate for Payer: PHCS Commercial	$2,445.12
Rate for Payer: United Healthcare All Payer	$2,241.36

REPAIR HERNIA FEM INCAR

Facility

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	76102018
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$1,728.00
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$1,494.00
Rate for Payer: First Health Commercial	$1,710.00
Rate for Payer: Humana Commercial	$1,530.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,476.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,328.40
Rate for Payer: Molina Healthcare Benefit Exchange	$540.00
Rate for Payer: Ohio Health Choice Commercial	$1,584.00
Rate for Payer: Ohio Health Group HMO	$1,350.00
Rate for Payer: Ohio Health Group PPO Differential	$360.00
Rate for Payer: Ohio Health Group PPO No Differential	$234.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$558.00
Rate for Payer: PHCS Commercial	$1,728.00
Rate for Payer: United Healthcare All Payer	$1,584.00

REPAIR HERNIA FEM INCAR

Facility

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	76102018
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$4,188.46
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem Medicaid	$619.02
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$1,494.00
Rate for Payer: First Health Commercial	$1,710.00
Rate for Payer: Humana Commercial	$1,530.00
Rate for Payer: Humana KY Medicaid	$619.02
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Kentucky WC Medicaid	$625.32
Rate for Payer: Medical Mutual Of Ohio HMO	$1,476.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,328.40
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11
Rate for Payer: Molina Healthcare Medicaid	$631.44
Rate for Payer: Ohio Health Choice Commercial	$1,584.00
Rate for Payer: Ohio Health Group HMO	$1,350.00
Rate for Payer: Ohio Health Group PPO Differential	$360.00
Rate for Payer: Ohio Health Group PPO No Differential	$234.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$558.00
Rate for Payer: PHCS Commercial	$1,728.00
Rate for Payer: United Healthcare All Payer	$1,584.00

REPAIR HERNIA FEM INCAR

Professional

Both

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	76102018
Hospital Revenue Code	761
Min. Negotiated Rate	$364.36
Max. Negotiated Rate	$1,800.00
Rate for Payer: Aetna Commercial	$897.71
Rate for Payer: Anthem Medicaid	$364.36
Rate for Payer: Buckeye Medicare Advantage	$1,800.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$835.96
Rate for Payer: Healthspan PPO	$757.05
Rate for Payer: Humana Medicaid	$364.36
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$798.04
Rate for Payer: Molina Healthcare CHIP/Medicaid	$371.65
Rate for Payer: Molina Healthcare Passport	$364.36
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,260.00
Rate for Payer: UHCCP Medicaid	$630.00
Rate for Payer: Wellcare CHIP/Medicaid	$368.00

REPAIR HERNIA FEM INCAR(P

Professional

Both

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	761P2018
Hospital Revenue Code	761
Min. Negotiated Rate	$364.36
Max. Negotiated Rate	$1,800.00
Rate for Payer: Aetna Commercial	$897.71
Rate for Payer: Anthem Medicaid	$364.36
Rate for Payer: Buckeye Medicare Advantage	$1,800.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$835.96
Rate for Payer: Healthspan PPO	$757.05
Rate for Payer: Humana Medicaid	$364.36
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$798.04
Rate for Payer: Molina Healthcare CHIP/Medicaid	$371.65
Rate for Payer: Molina Healthcare Passport	$364.36
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,260.00
Rate for Payer: UHCCP Medicaid	$630.00
Rate for Payer: Wellcare CHIP/Medicaid	$368.00

REPAIR HUMERUS WITH GRAFT

Professional

Both

$1,105.00

Service Code	HCPCS 24435
Hospital Charge Code	76102740
Hospital Revenue Code	360
Min. Negotiated Rate	$386.75
Max. Negotiated Rate	$1,694.30
Rate for Payer: Aetna Commercial	$1,566.08
Rate for Payer: Anthem Medicaid	$845.40
Rate for Payer: Buckeye Medicare Advantage	$1,105.00
Rate for Payer: Cash Price	$552.50
Rate for Payer: Cash Price	$552.50
Rate for Payer: Cigna Commercial	$1,694.30
Rate for Payer: Healthspan PPO	$1,418.54
Rate for Payer: Humana Medicaid	$845.40
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,337.23
Rate for Payer: Molina Healthcare CHIP/Medicaid	$862.31
Rate for Payer: Molina Healthcare Passport	$845.40
Rate for Payer: Multiplan PHCS	$663.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$773.50
Rate for Payer: UHCCP Medicaid	$386.75
Rate for Payer: Wellcare CHIP/Medicaid	$853.85

REPAIR ING HERNIA SLIDING

Facility

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$101.40
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna Commercial	$600.60
Rate for Payer: Anthem POS/PPO/Traditional	$608.40
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$647.40
Rate for Payer: First Health Commercial	$741.00
Rate for Payer: Humana Commercial	$663.00
Rate for Payer: Medical Mutual Of Ohio HMO	$639.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$575.64
Rate for Payer: Molina Healthcare Benefit Exchange	$234.00
Rate for Payer: Ohio Health Choice Commercial	$686.40
Rate for Payer: Ohio Health Group HMO	$585.00
Rate for Payer: Ohio Health Group PPO Differential	$156.00
Rate for Payer: Ohio Health Group PPO No Differential	$101.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$241.80
Rate for Payer: PHCS Commercial	$748.80
Rate for Payer: United Healthcare All Payer	$686.40

REPAIR ING HERNIA SLIDING

Facility

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$101.40
Max. Negotiated Rate	$4,188.46
Rate for Payer: Aetna Commercial	$600.60
Rate for Payer: Anthem Medicaid	$268.24
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Anthem POS/PPO/Traditional	$608.40
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$647.40
Rate for Payer: First Health Commercial	$741.00
Rate for Payer: Humana Commercial	$663.00
Rate for Payer: Humana KY Medicaid	$268.24
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Kentucky WC Medicaid	$270.97
Rate for Payer: Medical Mutual Of Ohio HMO	$639.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$575.64
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11
Rate for Payer: Molina Healthcare Medicaid	$273.62
Rate for Payer: Ohio Health Choice Commercial	$686.40
Rate for Payer: Ohio Health Group HMO	$585.00
Rate for Payer: Ohio Health Group PPO Differential	$156.00
Rate for Payer: Ohio Health Group PPO No Differential	$101.40
Rate for Payer: Ohio Health Group PPO SOMC Employees	$241.80
Rate for Payer: PHCS Commercial	$748.80
Rate for Payer: United Healthcare All Payer	$686.40

REPAIR ING HERNIA SLIDING

Professional

Both

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$816.13
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Anthem Medicaid	$381.57
Rate for Payer: Buckeye Medicare Advantage	$780.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$759.55
Rate for Payer: Healthspan PPO	$688.26
Rate for Payer: Humana Medicaid	$381.57
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$723.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$389.20
Rate for Payer: Molina Healthcare Passport	$381.57
Rate for Payer: Multiplan PHCS	$468.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$546.00
Rate for Payer: UHCCP Medicaid	$273.00
Rate for Payer: Wellcare CHIP/Medicaid	$385.39

REPAIR ING HERNIA SLIDING(P

Professional

Both

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	761P2016
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$816.13
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Anthem Medicaid	$381.57
Rate for Payer: Buckeye Medicare Advantage	$780.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$759.55
Rate for Payer: Healthspan PPO	$688.26
Rate for Payer: Humana Medicaid	$381.57
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$723.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$389.20
Rate for Payer: Molina Healthcare Passport	$381.57
Rate for Payer: Multiplan PHCS	$468.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$546.00
Rate for Payer: UHCCP Medicaid	$273.00
Rate for Payer: Wellcare CHIP/Medicaid	$385.39

REPAIR INGUINAL HERNIA, SLIDING, ANY AGE

Facility

$4,188.46

Service Code	CPT 49525
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED

Facility

$4,188.46

Service Code	CPT 49553
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE

Facility

$4,188.46

Service Code	CPT 49550
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED

Facility

$4,188.46

Service Code	CPT 49507
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE

Facility

$4,188.46

Service Code	CPT 49505
Hospital Revenue Code	360
Min. Negotiated Rate	$2,991.76
Max. Negotiated Rate	$4,188.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,991.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,188.46
Rate for Payer: CareSource Just4Me Medicare	$4,038.88
Rate for Payer: Humana Medicare Advantage	$2,991.76
Rate for Payer: Molina Healthcare Benefit Exchange	$3,590.11

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS

Facility

$482.75

Service Code	CPT 12051
Hospital Revenue Code	360
Min. Negotiated Rate	$344.82
Max. Negotiated Rate	$482.75
Rate for Payer: Anthem Medicare Advantage/PPO	$344.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.75
Rate for Payer: CareSource Just4Me Medicare	$465.51
Rate for Payer: Humana Medicare Advantage	$344.82
Rate for Payer: Molina Healthcare Benefit Exchange	$413.78

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

Facility

$482.75

Service Code	CPT 12053
Hospital Revenue Code	360
Min. Negotiated Rate	$344.82
Max. Negotiated Rate	$482.75
Rate for Payer: Anthem Medicare Advantage/PPO	$344.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.75
Rate for Payer: CareSource Just4Me Medicare	$465.51
Rate for Payer: Humana Medicare Advantage	$344.82
Rate for Payer: Molina Healthcare Benefit Exchange	$413.78

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS

Facility

$482.75

Service Code	CPT 12041
Hospital Revenue Code	360
Min. Negotiated Rate	$344.82
Max. Negotiated Rate	$482.75
Rate for Payer: Anthem Medicare Advantage/PPO	$344.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.75
Rate for Payer: CareSource Just4Me Medicare	$465.51
Rate for Payer: Humana Medicare Advantage	$344.82
Rate for Payer: Molina Healthcare Benefit Exchange	$413.78

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM

Facility

$482.75

Service Code	CPT 12042
Hospital Revenue Code	360
Min. Negotiated Rate	$344.82
Max. Negotiated Rate	$482.75
Rate for Payer: Anthem Medicare Advantage/PPO	$344.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.75
Rate for Payer: CareSource Just4Me Medicare	$465.51
Rate for Payer: Humana Medicare Advantage	$344.82
Rate for Payer: Molina Healthcare Benefit Exchange	$413.78

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM

Facility

$760.35

Service Code	CPT 12044
Hospital Revenue Code	360
Min. Negotiated Rate	$543.11
Max. Negotiated Rate	$760.35
Rate for Payer: Anthem Medicare Advantage/PPO	$543.11
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$760.35
Rate for Payer: CareSource Just4Me Medicare	$733.20
Rate for Payer: Humana Medicare Advantage	$543.11
Rate for Payer: Molina Healthcare Benefit Exchange	$651.73

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM

Facility

$482.75

Service Code	CPT 12035
Hospital Revenue Code	360
Min. Negotiated Rate	$344.82
Max. Negotiated Rate	$482.75
Rate for Payer: Anthem Medicare Advantage/PPO	$344.82
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.75
Rate for Payer: CareSource Just4Me Medicare	$465.51
Rate for Payer: Humana Medicare Advantage	$344.82
Rate for Payer: Molina Healthcare Benefit Exchange	$413.78

Know your out-of-pocket cost for care.

All Charges