Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

Facility

$910.14

Service Code	CPT 11421
Hospital Revenue Code	360
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$910.14
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$2,095.90

Service Code	CPT 11422
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$2,095.90

Service Code	CPT 11423
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM

Facility

$2,095.90

Service Code	CPT 11424
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$3,702.27

Service Code	CPT 11426
Hospital Revenue Code	360
Min. Negotiated Rate	$2,644.48
Max. Negotiated Rate	$3,702.27
Rate for Payer: Anthem Medicare Advantage/PPO	$2,644.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,702.27
Rate for Payer: CareSource Just4Me Medicare	$3,570.05
Rate for Payer: Humana Medicare Advantage	$2,644.48
Rate for Payer: Molina Healthcare Benefit Exchange	$3,173.38

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS

Facility

$910.14

Service Code	CPT 11400
Hospital Revenue Code	360
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$910.14
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM

Facility

$516.82

Service Code	CPT 11401
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$910.14

Service Code	CPT 11402
Hospital Revenue Code	360
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$910.14
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$910.14

Service Code	CPT 11403
Hospital Revenue Code	360
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$910.14
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM

Facility

$2,095.90

Service Code	CPT 11404
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM

Facility

$2,095.90

Service Code	CPT 11406
Hospital Revenue Code	360
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$2,095.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48

EXCISION - BENIGN LESION(P

Professional

Both

$350.00

Service Code	HCPCS 11441
Hospital Charge Code	761P0064
Hospital Revenue Code	761
Min. Negotiated Rate	$67.37
Max. Negotiated Rate	$216.66
Rate for Payer: Aetna Commercial	$178.81
Rate for Payer: Ambetter Exchange	$124.16
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$67.37
Rate for Payer: Anthem Medicaid	$70.52
Rate for Payer: Buckeye Individual/Medicaid	$124.16
Rate for Payer: Buckeye Medicare Advantage	$124.16
Rate for Payer: CareSource Just4Me Medicare	$148.99
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cigna Commercial	$216.66
Rate for Payer: Healthspan PPO	$178.06
Rate for Payer: Humana Medicaid	$70.52
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$159.28
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$124.16
Rate for Payer: Molina Healthcare Benefit Exchange	$124.16
Rate for Payer: Molina Healthcare CHIP/Medicaid	$71.93
Rate for Payer: Molina Healthcare Passport	$70.52
Rate for Payer: Multiplan PHCS	$210.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$161.41
Rate for Payer: UHCCP Medicaid	$70.74
Rate for Payer: Wellcare CHIP/Medicaid	$71.23
Rate for Payer: Wellcare Medicare Advantage	$124.16

EXCISION BENIGN LESION(P

Professional

Both

$300.00

Service Code	HCPCS 11421
Hospital Charge Code	761P0058
Hospital Revenue Code	761
Min. Negotiated Rate	$57.96
Max. Negotiated Rate	$199.93
Rate for Payer: Aetna Commercial	$154.48
Rate for Payer: Ambetter Exchange	$102.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$57.96
Rate for Payer: Anthem Medicaid	$64.17
Rate for Payer: Buckeye Individual/Medicaid	$102.40
Rate for Payer: Buckeye Medicare Advantage	$102.40
Rate for Payer: CareSource Just4Me Medicare	$122.88
Rate for Payer: Cash Price	$150.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Cigna Commercial	$199.93
Rate for Payer: Healthspan PPO	$166.73
Rate for Payer: Humana Medicaid	$64.17
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$135.73
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$102.40
Rate for Payer: Molina Healthcare Benefit Exchange	$102.40
Rate for Payer: Molina Healthcare CHIP/Medicaid	$65.45
Rate for Payer: Molina Healthcare Passport	$64.17
Rate for Payer: Multiplan PHCS	$180.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$133.12
Rate for Payer: UHCCP Medicaid	$60.86
Rate for Payer: Wellcare CHIP/Medicaid	$64.81
Rate for Payer: Wellcare Medicare Advantage	$102.40

EXCISION BENIGN LESION(P

Professional

Both

$550.00

Service Code	HCPCS 11406
Hospital Charge Code	761P0056
Hospital Revenue Code	761
Min. Negotiated Rate	$126.49
Max. Negotiated Rate	$378.50
Rate for Payer: Aetna Commercial	$331.75
Rate for Payer: Ambetter Exchange	$235.14
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$126.49
Rate for Payer: Anthem Medicaid	$137.96
Rate for Payer: Buckeye Individual/Medicaid	$235.14
Rate for Payer: Buckeye Medicare Advantage	$235.14
Rate for Payer: CareSource Just4Me Medicare	$282.17
Rate for Payer: Cash Price	$275.00
Rate for Payer: Cash Price	$275.00
Rate for Payer: Cigna Commercial	$378.50
Rate for Payer: Healthspan PPO	$325.61
Rate for Payer: Humana Medicaid	$137.96
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$297.86
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$235.14
Rate for Payer: Molina Healthcare Benefit Exchange	$235.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$140.72
Rate for Payer: Molina Healthcare Passport	$137.96
Rate for Payer: Multiplan PHCS	$330.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$305.68
Rate for Payer: UHCCP Medicaid	$132.81
Rate for Payer: Wellcare CHIP/Medicaid	$139.34
Rate for Payer: Wellcare Medicare Advantage	$235.14

EXCISION - BENIGN LESION(T

Facility

$1,816.00

Service Code	HCPCS 11441
Hospital Charge Code	761T0064
Hospital Revenue Code	761
Min. Negotiated Rate	$544.80
Max. Negotiated Rate	$1,743.36
Rate for Payer: Aetna Commercial	$1,398.32
Rate for Payer: Anthem POS/PPO/Traditional	$1,416.48
Rate for Payer: Cash Price	$908.00
Rate for Payer: Cigna Commercial	$1,507.28
Rate for Payer: First Health Commercial	$1,725.20
Rate for Payer: Humana Commercial	$1,543.60
Rate for Payer: Medical Mutual Of Ohio HMO	$1,489.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,340.21
Rate for Payer: Molina Healthcare Benefit Exchange	$544.80
Rate for Payer: Ohio Health Choice Commercial	$1,598.08
Rate for Payer: Ohio Health Group HMO	$1,362.00
Rate for Payer: Ohio Health Group PPO Differential	$1,452.80
Rate for Payer: Ohio Health Group PPO No Differential	$1,579.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,253.04
Rate for Payer: PHCS Commercial	$1,743.36
Rate for Payer: United Healthcare All Payer	$1,598.08

EXCISION - BENIGN LESION(T

Facility

$1,816.00

Service Code	HCPCS 11441
Hospital Charge Code	761T0064
Hospital Revenue Code	761
Min. Negotiated Rate	$624.52
Max. Negotiated Rate	$1,743.36
Rate for Payer: Aetna Commercial	$1,398.32
Rate for Payer: Anthem Medicaid	$624.52
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$1,416.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$908.00
Rate for Payer: Cash Price	$908.00
Rate for Payer: Cigna Commercial	$1,507.28
Rate for Payer: First Health Commercial	$1,725.20
Rate for Payer: Humana Commercial	$1,543.60
Rate for Payer: Humana KY Medicaid	$624.52
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$630.88
Rate for Payer: Medical Mutual Of Ohio HMO	$1,489.12
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,340.21
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$637.05
Rate for Payer: Ohio Health Choice Commercial	$1,598.08
Rate for Payer: Ohio Health Group HMO	$1,362.00
Rate for Payer: Ohio Health Group PPO Differential	$1,452.80
Rate for Payer: Ohio Health Group PPO No Differential	$1,579.92
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,253.04
Rate for Payer: PHCS Commercial	$1,743.36
Rate for Payer: United Healthcare All Payer	$1,598.08

EXCISION BENIGN LESION(T

Facility

$2,636.00

Service Code	HCPCS 11421
Hospital Charge Code	761T0058
Hospital Revenue Code	761
Min. Negotiated Rate	$790.80
Max. Negotiated Rate	$2,530.56
Rate for Payer: Aetna Commercial	$2,029.72
Rate for Payer: Anthem POS/PPO/Traditional	$2,056.08
Rate for Payer: Cash Price	$1,318.00
Rate for Payer: Cigna Commercial	$2,187.88
Rate for Payer: First Health Commercial	$2,504.20
Rate for Payer: Humana Commercial	$2,240.60
Rate for Payer: Medical Mutual Of Ohio HMO	$2,161.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,945.37
Rate for Payer: Molina Healthcare Benefit Exchange	$790.80
Rate for Payer: Ohio Health Choice Commercial	$2,319.68
Rate for Payer: Ohio Health Group HMO	$1,977.00
Rate for Payer: Ohio Health Group PPO Differential	$2,108.80
Rate for Payer: Ohio Health Group PPO No Differential	$2,293.32
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,818.84
Rate for Payer: PHCS Commercial	$2,530.56
Rate for Payer: United Healthcare All Payer	$2,319.68

EXCISION BENIGN LESION(T

Facility

$2,636.00

Service Code	HCPCS 11421
Hospital Charge Code	761T0058
Hospital Revenue Code	761
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$2,530.56
Rate for Payer: Aetna Commercial	$2,029.72
Rate for Payer: Anthem Medicaid	$906.52
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,056.08
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$1,318.00
Rate for Payer: Cash Price	$1,318.00
Rate for Payer: Cigna Commercial	$2,187.88
Rate for Payer: First Health Commercial	$2,504.20
Rate for Payer: Humana Commercial	$2,240.60
Rate for Payer: Humana KY Medicaid	$906.52
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$915.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,161.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,945.37
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$924.71
Rate for Payer: Ohio Health Choice Commercial	$2,319.68
Rate for Payer: Ohio Health Group HMO	$1,977.00
Rate for Payer: Ohio Health Group PPO Differential	$2,108.80
Rate for Payer: Ohio Health Group PPO No Differential	$2,293.32
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,818.84
Rate for Payer: PHCS Commercial	$2,530.56
Rate for Payer: United Healthcare All Payer	$2,319.68

EXCISION BENIGN LESION(T

Facility

$4,485.00

Service Code	HCPCS 11406
Hospital Charge Code	761T0056
Hospital Revenue Code	761
Min. Negotiated Rate	$1,497.07
Max. Negotiated Rate	$4,305.60
Rate for Payer: Aetna Commercial	$3,453.45
Rate for Payer: Anthem Medicaid	$1,542.39
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Anthem POS/PPO/Traditional	$3,498.30
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Cash Price	$2,242.50
Rate for Payer: Cash Price	$2,242.50
Rate for Payer: Cigna Commercial	$3,722.55
Rate for Payer: First Health Commercial	$4,260.75
Rate for Payer: Humana Commercial	$3,812.25
Rate for Payer: Humana KY Medicaid	$1,542.39
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Kentucky WC Medicaid	$1,558.09
Rate for Payer: Medical Mutual Of Ohio HMO	$3,677.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,309.93
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48
Rate for Payer: Molina Healthcare Medicaid	$1,573.34
Rate for Payer: Ohio Health Choice Commercial	$3,946.80
Rate for Payer: Ohio Health Group HMO	$3,363.75
Rate for Payer: Ohio Health Group PPO Differential	$3,588.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,901.95
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,094.65
Rate for Payer: PHCS Commercial	$4,305.60
Rate for Payer: United Healthcare All Payer	$3,946.80

EXCISION BENIGN LESION(T

Facility

$4,485.00

Service Code	HCPCS 11406
Hospital Charge Code	761T0056
Hospital Revenue Code	761
Min. Negotiated Rate	$1,345.50
Max. Negotiated Rate	$4,305.60
Rate for Payer: Aetna Commercial	$3,453.45
Rate for Payer: Anthem POS/PPO/Traditional	$3,498.30
Rate for Payer: Cash Price	$2,242.50
Rate for Payer: Cigna Commercial	$3,722.55
Rate for Payer: First Health Commercial	$4,260.75
Rate for Payer: Humana Commercial	$3,812.25
Rate for Payer: Medical Mutual Of Ohio HMO	$3,677.70
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,309.93
Rate for Payer: Molina Healthcare Benefit Exchange	$1,345.50
Rate for Payer: Ohio Health Choice Commercial	$3,946.80
Rate for Payer: Ohio Health Group HMO	$3,363.75
Rate for Payer: Ohio Health Group PPO Differential	$3,588.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,901.95
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,094.65
Rate for Payer: PHCS Commercial	$4,305.60
Rate for Payer: United Healthcare All Payer	$3,946.80

EXCISION BENIGN(P

Professional

Both

$250.00

Service Code	HCPCS 11420
Hospital Charge Code	761P0057
Hospital Revenue Code	761
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$156.41
Rate for Payer: Aetna Commercial	$113.91
Rate for Payer: Ambetter Exchange	$77.40
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$46.65
Rate for Payer: Anthem Medicaid	$44.80
Rate for Payer: Buckeye Individual/Medicaid	$77.40
Rate for Payer: Buckeye Medicare Advantage	$77.40
Rate for Payer: CareSource Just4Me Medicare	$92.88
Rate for Payer: Cash Price	$125.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Cigna Commercial	$156.41
Rate for Payer: Healthspan PPO	$127.88
Rate for Payer: Humana Medicaid	$44.80
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$98.81
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$77.40
Rate for Payer: Molina Healthcare Benefit Exchange	$77.40
Rate for Payer: Molina Healthcare CHIP/Medicaid	$45.70
Rate for Payer: Molina Healthcare Passport	$44.80
Rate for Payer: Multiplan PHCS	$150.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$100.62
Rate for Payer: UHCCP Medicaid	$48.98
Rate for Payer: Wellcare CHIP/Medicaid	$45.25
Rate for Payer: Wellcare Medicare Advantage	$77.40

EXCISION BENIGN(T

Facility

$2,184.00

Service Code	HCPCS 11420
Hospital Charge Code	761T0057
Hospital Revenue Code	761
Min. Negotiated Rate	$751.08
Max. Negotiated Rate	$2,096.64
Rate for Payer: Aetna Commercial	$1,681.68
Rate for Payer: Anthem Medicaid	$751.08
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Anthem POS/PPO/Traditional	$1,703.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Cash Price	$1,092.00
Rate for Payer: Cash Price	$1,092.00
Rate for Payer: Cigna Commercial	$1,812.72
Rate for Payer: First Health Commercial	$2,074.80
Rate for Payer: Humana Commercial	$1,856.40
Rate for Payer: Humana KY Medicaid	$751.08
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Kentucky WC Medicaid	$758.72
Rate for Payer: Medical Mutual Of Ohio HMO	$1,790.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,611.79
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48
Rate for Payer: Molina Healthcare Medicaid	$766.15
Rate for Payer: Ohio Health Choice Commercial	$1,921.92
Rate for Payer: Ohio Health Group HMO	$1,638.00
Rate for Payer: Ohio Health Group PPO Differential	$1,747.20
Rate for Payer: Ohio Health Group PPO No Differential	$1,900.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,506.96
Rate for Payer: PHCS Commercial	$2,096.64
Rate for Payer: United Healthcare All Payer	$1,921.92

EXCISION BENIGN(T

Facility

$2,184.00

Service Code	HCPCS 11420
Hospital Charge Code	761T0057
Hospital Revenue Code	761
Min. Negotiated Rate	$655.20
Max. Negotiated Rate	$2,096.64
Rate for Payer: Aetna Commercial	$1,681.68
Rate for Payer: Anthem POS/PPO/Traditional	$1,703.52
Rate for Payer: Cash Price	$1,092.00
Rate for Payer: Cigna Commercial	$1,812.72
Rate for Payer: First Health Commercial	$2,074.80
Rate for Payer: Humana Commercial	$1,856.40
Rate for Payer: Medical Mutual Of Ohio HMO	$1,790.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,611.79
Rate for Payer: Molina Healthcare Benefit Exchange	$655.20
Rate for Payer: Ohio Health Choice Commercial	$1,921.92
Rate for Payer: Ohio Health Group HMO	$1,638.00
Rate for Payer: Ohio Health Group PPO Differential	$1,747.20
Rate for Payer: Ohio Health Group PPO No Differential	$1,900.08
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,506.96
Rate for Payer: PHCS Commercial	$2,096.64
Rate for Payer: United Healthcare All Payer	$1,921.92

EXCISION BIOPSY - SUPERFICIAL

Facility

$3,372.00

Service Code	HCPCS 23065
Hospital Charge Code	76100436
Hospital Revenue Code	761
Min. Negotiated Rate	$1,159.63
Max. Negotiated Rate	$3,237.12
Rate for Payer: Aetna Commercial	$2,596.44
Rate for Payer: Anthem Medicaid	$1,159.63
Rate for Payer: Anthem Medicare Advantage/PPO	$1,497.07
Rate for Payer: Anthem POS/PPO/Traditional	$2,630.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,095.90
Rate for Payer: CareSource Just4Me Medicare	$2,021.04
Rate for Payer: Cash Price	$1,686.00
Rate for Payer: Cash Price	$1,686.00
Rate for Payer: Cigna Commercial	$2,798.76
Rate for Payer: First Health Commercial	$3,203.40
Rate for Payer: Humana Commercial	$2,866.20
Rate for Payer: Humana KY Medicaid	$1,159.63
Rate for Payer: Humana Medicare Advantage	$1,497.07
Rate for Payer: Kentucky WC Medicaid	$1,171.43
Rate for Payer: Medical Mutual Of Ohio HMO	$2,765.04
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,488.54
Rate for Payer: Molina Healthcare Benefit Exchange	$1,796.48
Rate for Payer: Molina Healthcare Medicaid	$1,182.90
Rate for Payer: Ohio Health Choice Commercial	$2,967.36
Rate for Payer: Ohio Health Group HMO	$2,529.00
Rate for Payer: Ohio Health Group PPO Differential	$2,697.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,933.64
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,326.68
Rate for Payer: PHCS Commercial	$3,237.12
Rate for Payer: United Healthcare All Payer	$2,967.36

EXCISION BIOPSY - SUPERFICIAL

Facility

$3,372.00

Service Code	HCPCS 23065
Hospital Charge Code	76100436
Hospital Revenue Code	761
Min. Negotiated Rate	$1,011.60
Max. Negotiated Rate	$3,237.12
Rate for Payer: Aetna Commercial	$2,596.44
Rate for Payer: Anthem POS/PPO/Traditional	$2,630.16
Rate for Payer: Cash Price	$1,686.00
Rate for Payer: Cigna Commercial	$2,798.76
Rate for Payer: First Health Commercial	$3,203.40
Rate for Payer: Humana Commercial	$2,866.20
Rate for Payer: Medical Mutual Of Ohio HMO	$2,765.04
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,488.54
Rate for Payer: Molina Healthcare Benefit Exchange	$1,011.60
Rate for Payer: Ohio Health Choice Commercial	$2,967.36
Rate for Payer: Ohio Health Group HMO	$2,529.00
Rate for Payer: Ohio Health Group PPO Differential	$2,697.60
Rate for Payer: Ohio Health Group PPO No Differential	$2,933.64
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,326.68
Rate for Payer: PHCS Commercial	$3,237.12
Rate for Payer: United Healthcare All Payer	$2,967.36

Know your out-of-pocket cost for care.

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