Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION OF SALIVARY CYST

Facility

$1,100.00

Service Code	HCPCS 42408
Hospital Charge Code	76101686
Hospital Revenue Code	761
Min. Negotiated Rate	$143.00
Max. Negotiated Rate	$3,897.84
Rate for Payer: Aetna Commercial	$847.00
Rate for Payer: Anthem Medicaid	$378.29
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$858.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,897.84
Rate for Payer: CareSource Just4Me Medicare	$3,758.63
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$913.00
Rate for Payer: First Health Commercial	$1,045.00
Rate for Payer: Humana Commercial	$935.00
Rate for Payer: Humana KY Medicaid	$378.29
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$382.14
Rate for Payer: Medical Mutual Of Ohio HMO	$902.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$811.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$385.88
Rate for Payer: Ohio Health Choice Commercial	$968.00
Rate for Payer: Ohio Health Group HMO	$825.00
Rate for Payer: Ohio Health Group PPO Differential	$220.00
Rate for Payer: Ohio Health Group PPO No Differential	$143.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$341.00
Rate for Payer: PHCS Commercial	$1,056.00
Rate for Payer: United Healthcare All Payer	$968.00

EXCISION OF SALIVARY CYST(P

Professional

Both

$1,100.00

Service Code	HCPCS 42408
Hospital Charge Code	761P1686
Hospital Revenue Code	761
Min. Negotiated Rate	$223.88
Max. Negotiated Rate	$1,100.00
Rate for Payer: Aetna Commercial	$478.95
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$223.88
Rate for Payer: Anthem Medicaid	$225.54
Rate for Payer: Buckeye Medicare Advantage	$1,100.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cash Price	$550.00
Rate for Payer: Cigna Commercial	$472.66
Rate for Payer: Healthspan PPO	$533.90
Rate for Payer: Humana Medicaid	$225.54
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$423.68
Rate for Payer: Molina Healthcare CHIP/Medicaid	$230.05
Rate for Payer: Molina Healthcare Passport	$225.54
Rate for Payer: Multiplan PHCS	$660.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$770.00
Rate for Payer: UHCCP Medicaid	$235.07
Rate for Payer: Wellcare CHIP/Medicaid	$227.80

EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR

Facility

$3,440.07

Service Code	CPT 11450
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 OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR

Facility

$3,440.07

Service Code	CPT 11462
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 OF STOMACH LESION

Facility

$2,000.00

Service Code	HCPCS 43610
Hospital Charge Code	76101783
Hospital Revenue Code	761
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,920.00
Rate for Payer: Aetna Commercial	$1,540.00
Rate for Payer: Anthem Medicaid	$687.80
Rate for Payer: Anthem POS/PPO/Traditional	$1,560.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cigna Commercial	$1,660.00
Rate for Payer: First Health Commercial	$1,900.00
Rate for Payer: Humana Commercial	$1,700.00
Rate for Payer: Humana KY Medicaid	$687.80
Rate for Payer: Kentucky WC Medicaid	$694.80
Rate for Payer: Medical Mutual Of Ohio HMO	$1,640.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,476.00
Rate for Payer: Molina Healthcare Benefit Exchange	$600.00
Rate for Payer: Molina Healthcare Medicaid	$701.60
Rate for Payer: Ohio Health Choice Commercial	$1,760.00
Rate for Payer: Ohio Health Group HMO	$1,500.00
Rate for Payer: Ohio Health Group PPO Differential	$400.00
Rate for Payer: Ohio Health Group PPO No Differential	$260.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$620.00
Rate for Payer: PHCS Commercial	$1,920.00
Rate for Payer: United Healthcare All Payer	$1,760.00

EXCISION OF STOMACH LESION

Professional

Both

$2,000.00

Service Code	HCPCS 43610
Hospital Charge Code	76101783
Hospital Revenue Code	761
Min. Negotiated Rate	$557.35
Max. Negotiated Rate	$2,000.00
Rate for Payer: Aetna Commercial	$1,411.83
Rate for Payer: Anthem Medicaid	$557.35
Rate for Payer: Buckeye Medicare Advantage	$2,000.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cigna Commercial	$1,311.13
Rate for Payer: Healthspan PPO	$1,190.62
Rate for Payer: Humana Medicaid	$557.35
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,251.07
Rate for Payer: Molina Healthcare CHIP/Medicaid	$568.50
Rate for Payer: Molina Healthcare Passport	$557.35
Rate for Payer: Multiplan PHCS	$1,200.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,400.00
Rate for Payer: UHCCP Medicaid	$700.00
Rate for Payer: Wellcare CHIP/Medicaid	$562.92

EXCISION OF STOMACH LESION

Facility

$2,000.00

Service Code	HCPCS 43610
Hospital Charge Code	76101783
Hospital Revenue Code	761
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,920.00
Rate for Payer: Aetna Commercial	$1,540.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,560.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cigna Commercial	$1,660.00
Rate for Payer: First Health Commercial	$1,900.00
Rate for Payer: Humana Commercial	$1,700.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,640.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,476.00
Rate for Payer: Molina Healthcare Benefit Exchange	$600.00
Rate for Payer: Ohio Health Choice Commercial	$1,760.00
Rate for Payer: Ohio Health Group HMO	$1,500.00
Rate for Payer: Ohio Health Group PPO Differential	$400.00
Rate for Payer: Ohio Health Group PPO No Differential	$260.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$620.00
Rate for Payer: PHCS Commercial	$1,920.00
Rate for Payer: United Healthcare All Payer	$1,760.00

EXCISION OF STOMACH LESION(P

Professional

Both

$2,000.00

Service Code	HCPCS 43610
Hospital Charge Code	761P1783
Hospital Revenue Code	761
Min. Negotiated Rate	$557.35
Max. Negotiated Rate	$2,000.00
Rate for Payer: Aetna Commercial	$1,411.83
Rate for Payer: Anthem Medicaid	$557.35
Rate for Payer: Buckeye Medicare Advantage	$2,000.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cash Price	$1,000.00
Rate for Payer: Cigna Commercial	$1,311.13
Rate for Payer: Healthspan PPO	$1,190.62
Rate for Payer: Humana Medicaid	$557.35
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,251.07
Rate for Payer: Molina Healthcare CHIP/Medicaid	$568.50
Rate for Payer: Molina Healthcare Passport	$557.35
Rate for Payer: Multiplan PHCS	$1,200.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,400.00
Rate for Payer: UHCCP Medicaid	$700.00
Rate for Payer: Wellcare CHIP/Medicaid	$562.92

EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND

Facility

$7,089.80

Service Code	CPT 42440
Hospital Revenue Code	360
Min. Negotiated Rate	$5,064.14
Max. Negotiated Rate	$7,089.80
Rate for Payer: Anthem Medicare Advantage/PPO	$5,064.14
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,089.80
Rate for Payer: CareSource Just4Me Medicare	$6,836.59
Rate for Payer: Humana Medicare Advantage	$5,064.14
Rate for Payer: Molina Healthcare Benefit Exchange	$6,076.97

EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL

Facility

$1,428.66

Service Code	CPT 46320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,020.47
Max. Negotiated Rate	$1,428.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,020.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,428.66
Rate for Payer: CareSource Just4Me Medicare	$1,377.63
Rate for Payer: Humana Medicare Advantage	$1,020.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,224.56

EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS;

Facility

$6,985.45

Service Code	CPT 60280
Hospital Revenue Code	360
Min. Negotiated Rate	$4,989.61
Max. Negotiated Rate	$6,985.45
Rate for Payer: Anthem Medicare Advantage/PPO	$4,989.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,985.45
Rate for Payer: CareSource Just4Me Medicare	$6,735.97
Rate for Payer: Humana Medicare Advantage	$4,989.61
Rate for Payer: Molina Healthcare Benefit Exchange	$5,987.53

EXCISION OF TONGUE LESION

Facility

$6,591.26

Service Code	HCPCS 41113
Hospital Charge Code	76101656
Hospital Revenue Code	761
Min. Negotiated Rate	$856.86
Max. Negotiated Rate	$6,327.61
Rate for Payer: Aetna Commercial	$5,075.27
Rate for Payer: Anthem Medicaid	$2,266.73
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$5,141.18
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,897.84
Rate for Payer: CareSource Just4Me Medicare	$3,758.63
Rate for Payer: Cash Price	$3,295.63
Rate for Payer: Cash Price	$3,295.63
Rate for Payer: Cigna Commercial	$5,470.75
Rate for Payer: First Health Commercial	$6,261.70
Rate for Payer: Humana Commercial	$5,602.57
Rate for Payer: Humana KY Medicaid	$2,266.73
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$2,289.80
Rate for Payer: Medical Mutual Of Ohio HMO	$5,404.83
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,864.35
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$2,312.21
Rate for Payer: Ohio Health Choice Commercial	$5,800.31
Rate for Payer: Ohio Health Group HMO	$4,943.44
Rate for Payer: Ohio Health Group PPO Differential	$1,318.25
Rate for Payer: Ohio Health Group PPO No Differential	$856.86
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,043.29
Rate for Payer: PHCS Commercial	$6,327.61
Rate for Payer: United Healthcare All Payer	$5,800.31

EXCISION OF TONGUE LESION

Professional

Both

$6,591.26

Service Code	HCPCS 41113
Hospital Charge Code	76101656
Hospital Revenue Code	761
Min. Negotiated Rate	$145.39
Max. Negotiated Rate	$6,591.26
Rate for Payer: Aetna Commercial	$394.78
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$184.72
Rate for Payer: Anthem Medicaid	$145.39
Rate for Payer: Buckeye Medicare Advantage	$6,591.26
Rate for Payer: Cash Price	$3,295.63
Rate for Payer: Cash Price	$3,295.63
Rate for Payer: Cigna Commercial	$473.89
Rate for Payer: Healthspan PPO	$417.78
Rate for Payer: Humana Medicaid	$145.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$353.42
Rate for Payer: Molina Healthcare CHIP/Medicaid	$148.30
Rate for Payer: Molina Healthcare Passport	$145.39
Rate for Payer: Multiplan PHCS	$3,954.76
Rate for Payer: Ohio Health Choice Preferred Health Choice	$4,613.88
Rate for Payer: UHCCP Medicaid	$193.96
Rate for Payer: Wellcare CHIP/Medicaid	$146.84

EXCISION OF TONGUE LESION

Facility

$6,591.26

Service Code	HCPCS 41113
Hospital Charge Code	76101656
Hospital Revenue Code	761
Min. Negotiated Rate	$856.86
Max. Negotiated Rate	$6,327.61
Rate for Payer: Aetna Commercial	$5,075.27
Rate for Payer: Anthem POS/PPO/Traditional	$5,141.18
Rate for Payer: Cash Price	$3,295.63
Rate for Payer: Cigna Commercial	$5,470.75
Rate for Payer: First Health Commercial	$6,261.70
Rate for Payer: Humana Commercial	$5,602.57
Rate for Payer: Medical Mutual Of Ohio HMO	$5,404.83
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,864.35
Rate for Payer: Molina Healthcare Benefit Exchange	$1,977.38
Rate for Payer: Ohio Health Choice Commercial	$5,800.31
Rate for Payer: Ohio Health Group HMO	$4,943.44
Rate for Payer: Ohio Health Group PPO Differential	$1,318.25
Rate for Payer: Ohio Health Group PPO No Differential	$856.86
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,043.29
Rate for Payer: PHCS Commercial	$6,327.61
Rate for Payer: United Healthcare All Payer	$5,800.31

EXCISION OF TONGUE LESION(P

Professional

Both

$830.00

Service Code	HCPCS 41113
Hospital Charge Code	761P1656
Hospital Revenue Code	761
Min. Negotiated Rate	$145.39
Max. Negotiated Rate	$830.00
Rate for Payer: Aetna Commercial	$394.78
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$184.72
Rate for Payer: Anthem Medicaid	$145.39
Rate for Payer: Buckeye Medicare Advantage	$830.00
Rate for Payer: Cash Price	$415.00
Rate for Payer: Cash Price	$415.00
Rate for Payer: Cigna Commercial	$473.89
Rate for Payer: Healthspan PPO	$417.78
Rate for Payer: Humana Medicaid	$145.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$353.42
Rate for Payer: Molina Healthcare CHIP/Medicaid	$148.30
Rate for Payer: Molina Healthcare Passport	$145.39
Rate for Payer: Multiplan PHCS	$498.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$581.00
Rate for Payer: UHCCP Medicaid	$193.96
Rate for Payer: Wellcare CHIP/Medicaid	$146.84

EXCISION OF TONGUE LESION(T

Facility

$5,761.26

Service Code	HCPCS 41113
Hospital Charge Code	761T1656
Hospital Revenue Code	761
Min. Negotiated Rate	$748.96
Max. Negotiated Rate	$5,530.81
Rate for Payer: Aetna Commercial	$4,436.17
Rate for Payer: Anthem Medicaid	$1,981.30
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$4,493.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,897.84
Rate for Payer: CareSource Just4Me Medicare	$3,758.63
Rate for Payer: Cash Price	$2,880.63
Rate for Payer: Cash Price	$2,880.63
Rate for Payer: Cigna Commercial	$4,781.85
Rate for Payer: First Health Commercial	$5,473.20
Rate for Payer: Humana Commercial	$4,897.07
Rate for Payer: Humana KY Medicaid	$1,981.30
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$2,001.46
Rate for Payer: Medical Mutual Of Ohio HMO	$4,724.23
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,251.81
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$2,021.05
Rate for Payer: Ohio Health Choice Commercial	$5,069.91
Rate for Payer: Ohio Health Group HMO	$4,320.94
Rate for Payer: Ohio Health Group PPO Differential	$1,152.25
Rate for Payer: Ohio Health Group PPO No Differential	$748.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,785.99
Rate for Payer: PHCS Commercial	$5,530.81
Rate for Payer: United Healthcare All Payer	$5,069.91

EXCISION OF TONGUE LESION(T

Facility

$5,761.26

Service Code	HCPCS 41113
Hospital Charge Code	761T1656
Hospital Revenue Code	761
Min. Negotiated Rate	$748.96
Max. Negotiated Rate	$5,530.81
Rate for Payer: Aetna Commercial	$4,436.17
Rate for Payer: Anthem POS/PPO/Traditional	$4,493.78
Rate for Payer: Cash Price	$2,880.63
Rate for Payer: Cigna Commercial	$4,781.85
Rate for Payer: First Health Commercial	$5,473.20
Rate for Payer: Humana Commercial	$4,897.07
Rate for Payer: Medical Mutual Of Ohio HMO	$4,724.23
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,251.81
Rate for Payer: Molina Healthcare Benefit Exchange	$1,728.38
Rate for Payer: Ohio Health Choice Commercial	$5,069.91
Rate for Payer: Ohio Health Group HMO	$4,320.94
Rate for Payer: Ohio Health Group PPO Differential	$1,152.25
Rate for Payer: Ohio Health Group PPO No Differential	$748.96
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,785.99
Rate for Payer: PHCS Commercial	$5,530.81
Rate for Payer: United Healthcare All Payer	$5,069.91

EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE

Facility

$6,264.36

Service Code	CPT 53230
Hospital Revenue Code	360
Min. Negotiated Rate	$4,474.54
Max. Negotiated Rate	$6,264.36
Rate for Payer: Anthem Medicare Advantage/PPO	$4,474.54
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,264.36
Rate for Payer: CareSource Just4Me Medicare	$6,040.63
Rate for Payer: Humana Medicare Advantage	$4,474.54
Rate for Payer: Molina Healthcare Benefit Exchange	$5,369.45

EXCISION OF UVULA

Professional

Both

$4,302.00

Service Code	HCPCS 42140
Hospital Charge Code	76101673
Hospital Revenue Code	761
Min. Negotiated Rate	$85.04
Max. Negotiated Rate	$4,302.00
Rate for Payer: Aetna Commercial	$217.44
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$93.90
Rate for Payer: Anthem Medicaid	$85.04
Rate for Payer: Buckeye Medicare Advantage	$4,302.00
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Cigna Commercial	$213.77
Rate for Payer: Healthspan PPO	$283.12
Rate for Payer: Humana Medicaid	$85.04
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$199.33
Rate for Payer: Molina Healthcare CHIP/Medicaid	$86.74
Rate for Payer: Molina Healthcare Passport	$85.04
Rate for Payer: Multiplan PHCS	$2,581.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$3,011.40
Rate for Payer: UHCCP Medicaid	$98.60
Rate for Payer: Wellcare CHIP/Medicaid	$85.89

EXCISION OF UVULA

Facility

$4,302.00

Service Code	HCPCS 42140
Hospital Charge Code	76101673
Hospital Revenue Code	761
Min. Negotiated Rate	$559.26
Max. Negotiated Rate	$4,129.92
Rate for Payer: Aetna Commercial	$3,312.54
Rate for Payer: Anthem Medicaid	$1,479.46
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$3,355.56
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,897.84
Rate for Payer: CareSource Just4Me Medicare	$3,758.63
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Cigna Commercial	$3,570.66
Rate for Payer: First Health Commercial	$4,086.90
Rate for Payer: Humana Commercial	$3,656.70
Rate for Payer: Humana KY Medicaid	$1,479.46
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$1,494.51
Rate for Payer: Medical Mutual Of Ohio HMO	$3,527.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,174.88
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$1,509.14
Rate for Payer: Ohio Health Choice Commercial	$3,785.76
Rate for Payer: Ohio Health Group HMO	$3,226.50
Rate for Payer: Ohio Health Group PPO Differential	$860.40
Rate for Payer: Ohio Health Group PPO No Differential	$559.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,333.62
Rate for Payer: PHCS Commercial	$4,129.92
Rate for Payer: United Healthcare All Payer	$3,785.76

EXCISION OF UVULA

Facility

$4,302.00

Service Code	HCPCS 42140
Hospital Charge Code	76101673
Hospital Revenue Code	761
Min. Negotiated Rate	$559.26
Max. Negotiated Rate	$4,129.92
Rate for Payer: Aetna Commercial	$3,312.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,355.56
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Cigna Commercial	$3,570.66
Rate for Payer: First Health Commercial	$4,086.90
Rate for Payer: Humana Commercial	$3,656.70
Rate for Payer: Medical Mutual Of Ohio HMO	$3,527.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,174.88
Rate for Payer: Molina Healthcare Benefit Exchange	$1,290.60
Rate for Payer: Ohio Health Choice Commercial	$3,785.76
Rate for Payer: Ohio Health Group HMO	$3,226.50
Rate for Payer: Ohio Health Group PPO Differential	$860.40
Rate for Payer: Ohio Health Group PPO No Differential	$559.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,333.62
Rate for Payer: PHCS Commercial	$4,129.92
Rate for Payer: United Healthcare All Payer	$3,785.76

EXCISION OF UVULA(P

Professional

Both

$550.00

Service Code	HCPCS 42140
Hospital Charge Code	761P1673
Hospital Revenue Code	761
Min. Negotiated Rate	$85.04
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$217.44
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$93.90
Rate for Payer: Anthem Medicaid	$85.04
Rate for Payer: Buckeye Medicare Advantage	$550.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Cigna Commercial	$213.77
Rate for Payer: Healthspan PPO	$283.12
Rate for Payer: Humana Medicaid	$85.04
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$199.33
Rate for Payer: Molina Healthcare CHIP/Medicaid	$86.74
Rate for Payer: Molina Healthcare Passport	$85.04
Rate for Payer: Multiplan PHCS	$330.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$385.00
Rate for Payer: UHCCP Medicaid	$98.60
Rate for Payer: Wellcare CHIP/Medicaid	$85.89

EXCISION OF UVULA(T

Facility

$3,752.00

Service Code	HCPCS 42140
Hospital Charge Code	761T1673
Hospital Revenue Code	761
Min. Negotiated Rate	$487.76
Max. Negotiated Rate	$3,601.92
Rate for Payer: Aetna Commercial	$2,889.04
Rate for Payer: Anthem POS/PPO/Traditional	$2,926.56
Rate for Payer: Cash Price	$1,876.00
Rate for Payer: Cigna Commercial	$3,114.16
Rate for Payer: First Health Commercial	$3,564.40
Rate for Payer: Humana Commercial	$3,189.20
Rate for Payer: Medical Mutual Of Ohio HMO	$3,076.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,768.98
Rate for Payer: Molina Healthcare Benefit Exchange	$1,125.60
Rate for Payer: Ohio Health Choice Commercial	$3,301.76
Rate for Payer: Ohio Health Group HMO	$2,814.00
Rate for Payer: Ohio Health Group PPO Differential	$750.40
Rate for Payer: Ohio Health Group PPO No Differential	$487.76
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,163.12
Rate for Payer: PHCS Commercial	$3,601.92
Rate for Payer: United Healthcare All Payer	$3,301.76

EXCISION OF UVULA(T

Facility

$3,752.00

Service Code	HCPCS 42140
Hospital Charge Code	761T1673
Hospital Revenue Code	761
Min. Negotiated Rate	$487.76
Max. Negotiated Rate	$3,897.84
Rate for Payer: Aetna Commercial	$2,889.04
Rate for Payer: Anthem Medicaid	$1,290.31
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$2,926.56
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,897.84
Rate for Payer: CareSource Just4Me Medicare	$3,758.63
Rate for Payer: Cash Price	$1,876.00
Rate for Payer: Cash Price	$1,876.00
Rate for Payer: Cigna Commercial	$3,114.16
Rate for Payer: First Health Commercial	$3,564.40
Rate for Payer: Humana Commercial	$3,189.20
Rate for Payer: Humana KY Medicaid	$1,290.31
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$1,303.44
Rate for Payer: Medical Mutual Of Ohio HMO	$3,076.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,768.98
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$1,316.20
Rate for Payer: Ohio Health Choice Commercial	$3,301.76
Rate for Payer: Ohio Health Group HMO	$2,814.00
Rate for Payer: Ohio Health Group PPO Differential	$750.40
Rate for Payer: Ohio Health Group PPO No Differential	$487.76
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,163.12
Rate for Payer: PHCS Commercial	$3,601.92
Rate for Payer: United Healthcare All Payer	$3,301.76

EXCISION OF VAGINAL CYST OR TUMOR

Facility

$3,784.94

Service Code	CPT 57135
Hospital Revenue Code	360
Min. Negotiated Rate	$2,703.53
Max. Negotiated Rate	$3,784.94
Rate for Payer: Anthem Medicare Advantage/PPO	$2,703.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,784.94
Rate for Payer: CareSource Just4Me Medicare	$3,649.77
Rate for Payer: Humana Medicare Advantage	$2,703.53
Rate for Payer: Molina Healthcare Benefit Exchange	$3,244.24

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