Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION LYMPHATIC SYSTEM(T

Facility

$7,460.25

Service Code	HCPCS 38542
Hospital Charge Code	761T1600
Hospital Revenue Code	761
Min. Negotiated Rate	$969.83
Max. Negotiated Rate	$7,161.84
Rate for Payer: Aetna Commercial	$5,744.39
Rate for Payer: Anthem Medicaid	$2,565.58
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Anthem POS/PPO/Traditional	$5,819.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Cash Price	$3,730.12
Rate for Payer: Cash Price	$3,730.12
Rate for Payer: Cigna Commercial	$6,192.01
Rate for Payer: First Health Commercial	$7,087.24
Rate for Payer: Humana Commercial	$6,341.21
Rate for Payer: Humana KY Medicaid	$2,565.58
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Kentucky WC Medicaid	$2,591.69
Rate for Payer: Medical Mutual Of Ohio HMO	$6,117.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,505.66
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53
Rate for Payer: Molina Healthcare Medicaid	$2,617.06
Rate for Payer: Ohio Health Choice Commercial	$6,565.02
Rate for Payer: Ohio Health Group HMO	$5,595.19
Rate for Payer: Ohio Health Group PPO Differential	$1,492.05
Rate for Payer: Ohio Health Group PPO No Differential	$969.83
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,312.68
Rate for Payer: PHCS Commercial	$7,161.84
Rate for Payer: United Healthcare All Payer	$6,565.02

EXCISION LYMPH NODE BREAST

Professional

Both

$6,074.50

Service Code	HCPCS 38530
Hospital Charge Code	76101598
Hospital Revenue Code	761
Min. Negotiated Rate	$271.60
Max. Negotiated Rate	$6,074.50
Rate for Payer: Aetna Commercial	$787.78
Rate for Payer: Anthem Medicaid	$271.60
Rate for Payer: Buckeye Medicare Advantage	$6,074.50
Rate for Payer: Cash Price	$3,037.25
Rate for Payer: Cash Price	$3,037.25
Rate for Payer: Cigna Commercial	$740.35
Rate for Payer: Healthspan PPO	$629.90
Rate for Payer: Humana Medicaid	$271.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$699.59
Rate for Payer: Molina Healthcare CHIP/Medicaid	$277.03
Rate for Payer: Molina Healthcare Passport	$271.60
Rate for Payer: Multiplan PHCS	$3,644.70
Rate for Payer: Ohio Health Choice Preferred Health Choice	$4,252.15
Rate for Payer: UHCCP Medicaid	$2,126.08
Rate for Payer: Wellcare CHIP/Medicaid	$274.32

EXCISION LYMPH NODE BREAST

Facility

$6,074.50

Service Code	HCPCS 38530
Hospital Charge Code	76101598
Hospital Revenue Code	761
Min. Negotiated Rate	$789.68
Max. Negotiated Rate	$5,831.52
Rate for Payer: Aetna Commercial	$4,677.36
Rate for Payer: Anthem POS/PPO/Traditional	$4,738.11
Rate for Payer: Cash Price	$3,037.25
Rate for Payer: Cigna Commercial	$5,041.84
Rate for Payer: First Health Commercial	$5,770.78
Rate for Payer: Humana Commercial	$5,163.32
Rate for Payer: Medical Mutual Of Ohio HMO	$4,981.09
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,482.98
Rate for Payer: Molina Healthcare Benefit Exchange	$1,822.35
Rate for Payer: Ohio Health Choice Commercial	$5,345.56
Rate for Payer: Ohio Health Group HMO	$4,555.88
Rate for Payer: Ohio Health Group PPO Differential	$1,214.90
Rate for Payer: Ohio Health Group PPO No Differential	$789.68
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,883.10
Rate for Payer: PHCS Commercial	$5,831.52
Rate for Payer: United Healthcare All Payer	$5,345.56

EXCISION LYMPH NODE BREAST

Facility

$6,074.50

Service Code	HCPCS 38530
Hospital Charge Code	76101598
Hospital Revenue Code	761
Min. Negotiated Rate	$789.68
Max. Negotiated Rate	$5,831.52
Rate for Payer: Aetna Commercial	$4,677.36
Rate for Payer: Anthem Medicaid	$2,089.02
Rate for Payer: Anthem Medicare Advantage/PPO	$3,296.21
Rate for Payer: Anthem POS/PPO/Traditional	$4,738.11
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,614.69
Rate for Payer: CareSource Just4Me Medicare	$4,449.88
Rate for Payer: Cash Price	$3,037.25
Rate for Payer: Cash Price	$3,037.25
Rate for Payer: Cigna Commercial	$5,041.84
Rate for Payer: First Health Commercial	$5,770.78
Rate for Payer: Humana Commercial	$5,163.32
Rate for Payer: Humana KY Medicaid	$2,089.02
Rate for Payer: Humana Medicare Advantage	$3,296.21
Rate for Payer: Kentucky WC Medicaid	$2,110.28
Rate for Payer: Medical Mutual Of Ohio HMO	$4,981.09
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,482.98
Rate for Payer: Molina Healthcare Benefit Exchange	$3,955.45
Rate for Payer: Molina Healthcare Medicaid	$2,130.93
Rate for Payer: Ohio Health Choice Commercial	$5,345.56
Rate for Payer: Ohio Health Group HMO	$4,555.88
Rate for Payer: Ohio Health Group PPO Differential	$1,214.90
Rate for Payer: Ohio Health Group PPO No Differential	$789.68
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,883.10
Rate for Payer: PHCS Commercial	$5,831.52
Rate for Payer: United Healthcare All Payer	$5,345.56

EXCISION LYMPH NODE BREAST(P

Professional

Both

$1,000.00

Service Code	HCPCS 38530
Hospital Charge Code	761P1598
Hospital Revenue Code	761
Min. Negotiated Rate	$271.60
Max. Negotiated Rate	$1,000.00
Rate for Payer: Aetna Commercial	$787.78
Rate for Payer: Anthem Medicaid	$271.60
Rate for Payer: Buckeye Medicare Advantage	$1,000.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cigna Commercial	$740.35
Rate for Payer: Healthspan PPO	$629.90
Rate for Payer: Humana Medicaid	$271.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$699.59
Rate for Payer: Molina Healthcare CHIP/Medicaid	$277.03
Rate for Payer: Molina Healthcare Passport	$271.60
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
Rate for Payer: Wellcare CHIP/Medicaid	$274.32

EXCISION LYMPH NODE BREAST(T

Facility

$5,074.50

Service Code	HCPCS 38530
Hospital Charge Code	761T1598
Hospital Revenue Code	761
Min. Negotiated Rate	$659.68
Max. Negotiated Rate	$4,871.52
Rate for Payer: Aetna Commercial	$3,907.36
Rate for Payer: Anthem POS/PPO/Traditional	$3,958.11
Rate for Payer: Cash Price	$2,537.25
Rate for Payer: Cigna Commercial	$4,211.84
Rate for Payer: First Health Commercial	$4,820.78
Rate for Payer: Humana Commercial	$4,313.32
Rate for Payer: Medical Mutual Of Ohio HMO	$4,161.09
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,744.98
Rate for Payer: Molina Healthcare Benefit Exchange	$1,522.35
Rate for Payer: Ohio Health Choice Commercial	$4,465.56
Rate for Payer: Ohio Health Group HMO	$3,805.88
Rate for Payer: Ohio Health Group PPO Differential	$1,014.90
Rate for Payer: Ohio Health Group PPO No Differential	$659.68
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,573.10
Rate for Payer: PHCS Commercial	$4,871.52
Rate for Payer: United Healthcare All Payer	$4,465.56

EXCISION LYMPH NODE BREAST(T

Facility

$5,074.50

Service Code	HCPCS 38530
Hospital Charge Code	761T1598
Hospital Revenue Code	761
Min. Negotiated Rate	$659.68
Max. Negotiated Rate	$4,871.52
Rate for Payer: Aetna Commercial	$3,907.36
Rate for Payer: Anthem Medicaid	$1,745.12
Rate for Payer: Anthem Medicare Advantage/PPO	$3,296.21
Rate for Payer: Anthem POS/PPO/Traditional	$3,958.11
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,614.69
Rate for Payer: CareSource Just4Me Medicare	$4,449.88
Rate for Payer: Cash Price	$2,537.25
Rate for Payer: Cash Price	$2,537.25
Rate for Payer: Cigna Commercial	$4,211.84
Rate for Payer: First Health Commercial	$4,820.78
Rate for Payer: Humana Commercial	$4,313.32
Rate for Payer: Humana KY Medicaid	$1,745.12
Rate for Payer: Humana Medicare Advantage	$3,296.21
Rate for Payer: Kentucky WC Medicaid	$1,762.88
Rate for Payer: Medical Mutual Of Ohio HMO	$4,161.09
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,744.98
Rate for Payer: Molina Healthcare Benefit Exchange	$3,955.45
Rate for Payer: Molina Healthcare Medicaid	$1,780.13
Rate for Payer: Ohio Health Choice Commercial	$4,465.56
Rate for Payer: Ohio Health Group HMO	$3,805.88
Rate for Payer: Ohio Health Group PPO Differential	$1,014.90
Rate for Payer: Ohio Health Group PPO No Differential	$659.68
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,573.10
Rate for Payer: PHCS Commercial	$4,871.52
Rate for Payer: United Healthcare All Payer	$4,465.56

EXCISION - MALIGNANT LESION

Facility

$3,582.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$465.66
Max. Negotiated Rate	$3,438.72
Rate for Payer: Aetna Commercial	$2,758.14
Rate for Payer: Anthem POS/PPO/Traditional	$2,793.96
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Cigna Commercial	$2,973.06
Rate for Payer: First Health Commercial	$3,402.90
Rate for Payer: Humana Commercial	$3,044.70
Rate for Payer: Medical Mutual Of Ohio HMO	$2,937.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,643.52
Rate for Payer: Molina Healthcare Benefit Exchange	$1,074.60
Rate for Payer: Ohio Health Choice Commercial	$3,152.16
Rate for Payer: Ohio Health Group HMO	$2,686.50
Rate for Payer: Ohio Health Group PPO Differential	$716.40
Rate for Payer: Ohio Health Group PPO No Differential	$465.66
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,110.42
Rate for Payer: PHCS Commercial	$3,438.72
Rate for Payer: United Healthcare All Payer	$3,152.16

EXCISION - MALIGNANT LESION

Facility

$3,582.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$465.66
Max. Negotiated Rate	$3,438.72
Rate for Payer: Aetna Commercial	$2,758.14
Rate for Payer: Anthem Medicaid	$1,231.85
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Anthem POS/PPO/Traditional	$2,793.96
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Cigna Commercial	$2,973.06
Rate for Payer: First Health Commercial	$3,402.90
Rate for Payer: Humana Commercial	$3,044.70
Rate for Payer: Humana KY Medicaid	$1,231.85
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Kentucky WC Medicaid	$1,244.39
Rate for Payer: Medical Mutual Of Ohio HMO	$2,937.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,643.52
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10
Rate for Payer: Molina Healthcare Medicaid	$1,256.57
Rate for Payer: Ohio Health Choice Commercial	$3,152.16
Rate for Payer: Ohio Health Group HMO	$2,686.50
Rate for Payer: Ohio Health Group PPO Differential	$716.40
Rate for Payer: Ohio Health Group PPO No Differential	$465.66
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,110.42
Rate for Payer: PHCS Commercial	$3,438.72
Rate for Payer: United Healthcare All Payer	$3,152.16

EXCISION - MALIGNANT LESION

Professional

Both

$3,582.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$3,582.00
Rate for Payer: Aetna Commercial	$260.92
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$115.61
Rate for Payer: Anthem Medicaid	$124.56
Rate for Payer: Buckeye Medicare Advantage	$3,582.00
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Cash Price	$1,791.00
Rate for Payer: Cigna Commercial	$343.45
Rate for Payer: Healthspan PPO	$295.07
Rate for Payer: Humana Medicaid	$124.56
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$230.44
Rate for Payer: Molina Healthcare CHIP/Medicaid	$127.05
Rate for Payer: Molina Healthcare Passport	$124.56
Rate for Payer: Multiplan PHCS	$2,149.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,507.40
Rate for Payer: UHCCP Medicaid	$121.39
Rate for Payer: Wellcare CHIP/Medicaid	$125.81

EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$851.79

Service Code	CPT 11642
Hospital Revenue Code	360
Min. Negotiated Rate	$608.42
Max. Negotiated Rate	$851.79
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10

EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$1,962.83

Service Code	CPT 11643
Hospital Revenue Code	360
Min. Negotiated Rate	$1,402.02
Max. Negotiated Rate	$1,962.83
Rate for Payer: Anthem Medicare Advantage/PPO	$1,402.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,962.83
Rate for Payer: CareSource Just4Me Medicare	$1,892.73
Rate for Payer: Humana Medicare Advantage	$1,402.02
Rate for Payer: Molina Healthcare Benefit Exchange	$1,682.42

EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM

Facility

$3,440.07

Service Code	CPT 11646
Hospital Revenue Code	360
Min. Negotiated Rate	$2,457.19
Max. Negotiated Rate	$3,440.07
Rate for Payer: Anthem Medicare Advantage/PPO	$2,457.19
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,440.07
Rate for Payer: CareSource Just4Me Medicare	$3,317.21
Rate for Payer: Humana Medicare Advantage	$2,457.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,948.63

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$851.79

Service Code	CPT 11622
Hospital Revenue Code	360
Min. Negotiated Rate	$608.42
Max. Negotiated Rate	$851.79
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$1,962.83

Service Code	CPT 11623
Hospital Revenue Code	360
Min. Negotiated Rate	$1,402.02
Max. Negotiated Rate	$1,962.83
Rate for Payer: Anthem Medicare Advantage/PPO	$1,402.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,962.83
Rate for Payer: CareSource Just4Me Medicare	$1,892.73
Rate for Payer: Humana Medicare Advantage	$1,402.02
Rate for Payer: Molina Healthcare Benefit Exchange	$1,682.42

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$3,440.07

Service Code	CPT 11626
Hospital Revenue Code	360
Min. Negotiated Rate	$2,457.19
Max. Negotiated Rate	$3,440.07
Rate for Payer: Anthem Medicare Advantage/PPO	$2,457.19
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,440.07
Rate for Payer: CareSource Just4Me Medicare	$3,317.21
Rate for Payer: Humana Medicare Advantage	$2,457.19
Rate for Payer: Molina Healthcare Benefit Exchange	$2,948.63

EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$851.79

Service Code	CPT 11603
Hospital Revenue Code	360
Min. Negotiated Rate	$608.42
Max. Negotiated Rate	$851.79
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10

EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM

Facility

$851.79

Service Code	CPT 11604
Hospital Revenue Code	361
Min. Negotiated Rate	$608.42
Max. Negotiated Rate	$851.79
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10

EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM

Facility

$1,962.83

Service Code	CPT 11606
Hospital Revenue Code	360
Min. Negotiated Rate	$1,402.02
Max. Negotiated Rate	$1,962.83
Rate for Payer: Anthem Medicare Advantage/PPO	$1,402.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,962.83
Rate for Payer: CareSource Just4Me Medicare	$1,892.73
Rate for Payer: Humana Medicare Advantage	$1,402.02
Rate for Payer: Molina Healthcare Benefit Exchange	$1,682.42

EXCISION - MALIGNANT LESION(P

Professional

Both

$650.00

Service Code	HCPCS 11642
Hospital Charge Code	761P0089
Hospital Revenue Code	761
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$650.00
Rate for Payer: Aetna Commercial	$260.92
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$115.61
Rate for Payer: Anthem Medicaid	$124.56
Rate for Payer: Buckeye Medicare Advantage	$650.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Cigna Commercial	$343.45
Rate for Payer: Healthspan PPO	$295.07
Rate for Payer: Humana Medicaid	$124.56
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$230.44
Rate for Payer: Molina Healthcare CHIP/Medicaid	$127.05
Rate for Payer: Molina Healthcare Passport	$124.56
Rate for Payer: Multiplan PHCS	$390.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$455.00
Rate for Payer: UHCCP Medicaid	$121.39
Rate for Payer: Wellcare CHIP/Medicaid	$125.81

EXCISION - MALIGNANT LESION(T

Facility

$2,932.00

Service Code	HCPCS 11642
Hospital Charge Code	761T0089
Hospital Revenue Code	761
Min. Negotiated Rate	$381.16
Max. Negotiated Rate	$2,814.72
Rate for Payer: Aetna Commercial	$2,257.64
Rate for Payer: Anthem POS/PPO/Traditional	$2,286.96
Rate for Payer: Cash Price	$1,466.00
Rate for Payer: Cigna Commercial	$2,433.56
Rate for Payer: First Health Commercial	$2,785.40
Rate for Payer: Humana Commercial	$2,492.20
Rate for Payer: Medical Mutual Of Ohio HMO	$2,404.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,163.82
Rate for Payer: Molina Healthcare Benefit Exchange	$879.60
Rate for Payer: Ohio Health Choice Commercial	$2,580.16
Rate for Payer: Ohio Health Group HMO	$2,199.00
Rate for Payer: Ohio Health Group PPO Differential	$586.40
Rate for Payer: Ohio Health Group PPO No Differential	$381.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$908.92
Rate for Payer: PHCS Commercial	$2,814.72
Rate for Payer: United Healthcare All Payer	$2,580.16

EXCISION - MALIGNANT LESION(T

Facility

$2,932.00

Service Code	HCPCS 11642
Hospital Charge Code	761T0089
Hospital Revenue Code	761
Min. Negotiated Rate	$381.16
Max. Negotiated Rate	$2,814.72
Rate for Payer: Aetna Commercial	$2,257.64
Rate for Payer: Anthem Medicaid	$1,008.31
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Anthem POS/PPO/Traditional	$2,286.96
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Cash Price	$1,466.00
Rate for Payer: Cash Price	$1,466.00
Rate for Payer: Cigna Commercial	$2,433.56
Rate for Payer: First Health Commercial	$2,785.40
Rate for Payer: Humana Commercial	$2,492.20
Rate for Payer: Humana KY Medicaid	$1,008.31
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Kentucky WC Medicaid	$1,018.58
Rate for Payer: Medical Mutual Of Ohio HMO	$2,404.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,163.82
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10
Rate for Payer: Molina Healthcare Medicaid	$1,028.55
Rate for Payer: Ohio Health Choice Commercial	$2,580.16
Rate for Payer: Ohio Health Group HMO	$2,199.00
Rate for Payer: Ohio Health Group PPO Differential	$586.40
Rate for Payer: Ohio Health Group PPO No Differential	$381.16
Rate for Payer: Ohio Health Group PPO SOMC Employees	$908.92
Rate for Payer: PHCS Commercial	$2,814.72
Rate for Payer: United Healthcare All Payer	$2,580.16

EXCISION - NASAL LESION UP TO

Facility

$2,652.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$344.76
Max. Negotiated Rate	$2,545.92
Rate for Payer: Aetna Commercial	$2,042.04
Rate for Payer: Anthem POS/PPO/Traditional	$2,068.56
Rate for Payer: Cash Price	$1,326.00
Rate for Payer: Cigna Commercial	$2,201.16
Rate for Payer: First Health Commercial	$2,519.40
Rate for Payer: Humana Commercial	$2,254.20
Rate for Payer: Medical Mutual Of Ohio HMO	$2,174.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,957.18
Rate for Payer: Molina Healthcare Benefit Exchange	$795.60
Rate for Payer: Ohio Health Choice Commercial	$2,333.76
Rate for Payer: Ohio Health Group HMO	$1,989.00
Rate for Payer: Ohio Health Group PPO Differential	$530.40
Rate for Payer: Ohio Health Group PPO No Differential	$344.76
Rate for Payer: Ohio Health Group PPO SOMC Employees	$822.12
Rate for Payer: PHCS Commercial	$2,545.92
Rate for Payer: United Healthcare All Payer	$2,333.76

EXCISION - NASAL LESION UP TO

Facility

$2,652.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$344.76
Max. Negotiated Rate	$2,545.92
Rate for Payer: Aetna Commercial	$2,042.04
Rate for Payer: Anthem Medicaid	$912.02
Rate for Payer: Anthem Medicare Advantage/PPO	$608.42
Rate for Payer: Anthem POS/PPO/Traditional	$2,068.56
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$851.79
Rate for Payer: CareSource Just4Me Medicare	$821.37
Rate for Payer: Cash Price	$1,326.00
Rate for Payer: Cash Price	$1,326.00
Rate for Payer: Cigna Commercial	$2,201.16
Rate for Payer: First Health Commercial	$2,519.40
Rate for Payer: Humana Commercial	$2,254.20
Rate for Payer: Humana KY Medicaid	$912.02
Rate for Payer: Humana Medicare Advantage	$608.42
Rate for Payer: Kentucky WC Medicaid	$921.30
Rate for Payer: Medical Mutual Of Ohio HMO	$2,174.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,957.18
Rate for Payer: Molina Healthcare Benefit Exchange	$730.10
Rate for Payer: Molina Healthcare Medicaid	$930.32
Rate for Payer: Ohio Health Choice Commercial	$2,333.76
Rate for Payer: Ohio Health Group HMO	$1,989.00
Rate for Payer: Ohio Health Group PPO Differential	$530.40
Rate for Payer: Ohio Health Group PPO No Differential	$344.76
Rate for Payer: Ohio Health Group PPO SOMC Employees	$822.12
Rate for Payer: PHCS Commercial	$2,545.92
Rate for Payer: United Healthcare All Payer	$2,333.76

EXCISION - NASAL LESION UP TO

Professional

Both

$2,652.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$102.53
Max. Negotiated Rate	$2,652.00
Rate for Payer: Aetna Commercial	$221.03
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$113.16
Rate for Payer: Anthem Medicaid	$102.53
Rate for Payer: Buckeye Medicare Advantage	$2,652.00
Rate for Payer: Cash Price	$1,326.00
Rate for Payer: Cash Price	$1,326.00
Rate for Payer: Cigna Commercial	$297.19
Rate for Payer: Healthspan PPO	$255.48
Rate for Payer: Humana Medicaid	$102.53
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$195.60
Rate for Payer: Molina Healthcare CHIP/Medicaid	$104.58
Rate for Payer: Molina Healthcare Passport	$102.53
Rate for Payer: Multiplan PHCS	$1,591.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,856.40
Rate for Payer: UHCCP Medicaid	$118.82
Rate for Payer: Wellcare CHIP/Medicaid	$103.56

Know your out-of-pocket cost for care.

All Charges