Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION LYMPH NODE BREAST(T

Facility

$5,075.00

Service Code	HCPCS 38530
Hospital Charge Code	761T1598
Hospital Revenue Code	761
Min. Negotiated Rate	$1,745.29
Max. Negotiated Rate	$4,953.45
Rate for Payer: Aetna Commercial	$3,907.75
Rate for Payer: Anthem Medicaid	$1,745.29
Rate for Payer: Anthem Medicare Advantage/PPO	$3,538.18
Rate for Payer: Anthem POS/PPO/Traditional	$3,958.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,953.45
Rate for Payer: CareSource Just4Me Medicare	$4,776.54
Rate for Payer: Cash Price	$2,537.50
Rate for Payer: Cash Price	$2,537.50
Rate for Payer: Cigna Commercial	$4,212.25
Rate for Payer: First Health Commercial	$4,821.25
Rate for Payer: Humana Commercial	$4,313.75
Rate for Payer: Humana KY Medicaid	$1,745.29
Rate for Payer: Humana Medicare Advantage	$3,538.18
Rate for Payer: Kentucky WC Medicaid	$1,763.06
Rate for Payer: Medical Mutual Of Ohio HMO	$4,161.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,745.35
Rate for Payer: Molina Healthcare Benefit Exchange	$4,245.82
Rate for Payer: Molina Healthcare Medicaid	$1,780.31
Rate for Payer: Ohio Health Choice Commercial	$4,466.00
Rate for Payer: Ohio Health Group HMO	$3,806.25
Rate for Payer: Ohio Health Group PPO Differential	$4,060.00
Rate for Payer: Ohio Health Group PPO No Differential	$4,415.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,501.75
Rate for Payer: PHCS Commercial	$4,872.00
Rate for Payer: United Healthcare All Payer	$4,466.00

EXCISION LYMPH NODE BREAST(T

Facility

$5,075.00

Service Code	HCPCS 38530
Hospital Charge Code	761T1598
Hospital Revenue Code	761
Min. Negotiated Rate	$1,522.50
Max. Negotiated Rate	$4,872.00
Rate for Payer: Aetna Commercial	$3,907.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,958.50
Rate for Payer: Cash Price	$2,537.50
Rate for Payer: Cigna Commercial	$4,212.25
Rate for Payer: First Health Commercial	$4,821.25
Rate for Payer: Humana Commercial	$4,313.75
Rate for Payer: Medical Mutual Of Ohio HMO	$4,161.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,745.35
Rate for Payer: Molina Healthcare Benefit Exchange	$1,522.50
Rate for Payer: Ohio Health Choice Commercial	$4,466.00
Rate for Payer: Ohio Health Group HMO	$3,806.25
Rate for Payer: Ohio Health Group PPO Differential	$4,060.00
Rate for Payer: Ohio Health Group PPO No Differential	$4,415.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,501.75
Rate for Payer: PHCS Commercial	$4,872.00
Rate for Payer: United Healthcare All Payer	$4,466.00

EXCISION - MALIGNANT LESION

Professional

Both

$3,773.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$2,263.80
Rate for Payer: Aetna Commercial	$260.92
Rate for Payer: Ambetter Exchange	$170.33
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$115.61
Rate for Payer: Anthem Medicaid	$159.03
Rate for Payer: Buckeye Individual/Medicaid	$170.33
Rate for Payer: Buckeye Medicare Advantage	$170.33
Rate for Payer: CareSource Just4Me Medicare	$204.40
Rate for Payer: Cash Price	$1,886.50
Rate for Payer: Cash Price	$1,886.50
Rate for Payer: Cigna Commercial	$343.45
Rate for Payer: Healthspan PPO	$295.07
Rate for Payer: Humana Medicaid	$159.03
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$230.44
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$170.33
Rate for Payer: Molina Healthcare Benefit Exchange	$170.33
Rate for Payer: Molina Healthcare CHIP/Medicaid	$162.21
Rate for Payer: Molina Healthcare Passport	$159.03
Rate for Payer: Multiplan PHCS	$2,263.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$221.43
Rate for Payer: UHCCP Medicaid	$121.39
Rate for Payer: Wellcare CHIP/Medicaid	$160.62
Rate for Payer: Wellcare Medicare Advantage	$170.33

EXCISION - MALIGNANT LESION

Facility

$3,773.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$3,622.08
Rate for Payer: Aetna Commercial	$2,905.21
Rate for Payer: Anthem Medicaid	$1,297.53
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,942.94
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$1,886.50
Rate for Payer: Cash Price	$1,886.50
Rate for Payer: Cigna Commercial	$3,131.59
Rate for Payer: First Health Commercial	$3,584.35
Rate for Payer: Humana Commercial	$3,207.05
Rate for Payer: Humana KY Medicaid	$1,297.53
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$1,310.74
Rate for Payer: Medical Mutual Of Ohio HMO	$3,093.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,784.47
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$1,323.57
Rate for Payer: Ohio Health Choice Commercial	$3,320.24
Rate for Payer: Ohio Health Group HMO	$2,829.75
Rate for Payer: Ohio Health Group PPO Differential	$3,018.40
Rate for Payer: Ohio Health Group PPO No Differential	$3,282.51
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,603.37
Rate for Payer: PHCS Commercial	$3,622.08
Rate for Payer: United Healthcare All Payer	$3,320.24

EXCISION - MALIGNANT LESION

Facility

$3,773.00

Service Code	HCPCS 11642
Hospital Charge Code	76100089
Hospital Revenue Code	761
Min. Negotiated Rate	$1,131.90
Max. Negotiated Rate	$3,622.08
Rate for Payer: Aetna Commercial	$2,905.21
Rate for Payer: Anthem POS/PPO/Traditional	$2,942.94
Rate for Payer: Cash Price	$1,886.50
Rate for Payer: Cigna Commercial	$3,131.59
Rate for Payer: First Health Commercial	$3,584.35
Rate for Payer: Humana Commercial	$3,207.05
Rate for Payer: Medical Mutual Of Ohio HMO	$3,093.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,784.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,131.90
Rate for Payer: Ohio Health Choice Commercial	$3,320.24
Rate for Payer: Ohio Health Group HMO	$2,829.75
Rate for Payer: Ohio Health Group PPO Differential	$3,018.40
Rate for Payer: Ohio Health Group PPO No Differential	$3,282.51
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,603.37
Rate for Payer: PHCS Commercial	$3,622.08
Rate for Payer: United Healthcare All Payer	$3,320.24

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

Facility

$910.14

Service Code	CPT 11642
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, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$2,095.90

Service Code	CPT 11643
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, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM

Facility

$3,702.27

Service Code	CPT 11646
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, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$910.14

Service Code	CPT 11622
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, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$2,095.90

Service Code	CPT 11623
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, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$3,702.27

Service Code	CPT 11626
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, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$910.14

Service Code	CPT 11603
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, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM

Facility

$910.14

Service Code	CPT 11604
Hospital Revenue Code	361
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, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM

Facility

$2,095.90

Service Code	CPT 11606
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 - 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	$390.00
Rate for Payer: Aetna Commercial	$260.92
Rate for Payer: Ambetter Exchange	$170.33
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$115.61
Rate for Payer: Anthem Medicaid	$159.03
Rate for Payer: Buckeye Individual/Medicaid	$170.33
Rate for Payer: Buckeye Medicare Advantage	$170.33
Rate for Payer: CareSource Just4Me Medicare	$204.40
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	$159.03
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$230.44
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$170.33
Rate for Payer: Molina Healthcare Benefit Exchange	$170.33
Rate for Payer: Molina Healthcare CHIP/Medicaid	$162.21
Rate for Payer: Molina Healthcare Passport	$159.03
Rate for Payer: Multiplan PHCS	$390.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$221.43
Rate for Payer: UHCCP Medicaid	$121.39
Rate for Payer: Wellcare CHIP/Medicaid	$160.62
Rate for Payer: Wellcare Medicare Advantage	$170.33

EXCISION - MALIGNANT LESION(T

Facility

$3,123.00

Service Code	HCPCS 11642
Hospital Charge Code	761T0089
Hospital Revenue Code	761
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$2,998.08
Rate for Payer: Aetna Commercial	$2,404.71
Rate for Payer: Anthem Medicaid	$1,074.00
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,435.94
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$1,561.50
Rate for Payer: Cash Price	$1,561.50
Rate for Payer: Cigna Commercial	$2,592.09
Rate for Payer: First Health Commercial	$2,966.85
Rate for Payer: Humana Commercial	$2,654.55
Rate for Payer: Humana KY Medicaid	$1,074.00
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$1,084.93
Rate for Payer: Medical Mutual Of Ohio HMO	$2,560.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,304.77
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$1,095.55
Rate for Payer: Ohio Health Choice Commercial	$2,748.24
Rate for Payer: Ohio Health Group HMO	$2,342.25
Rate for Payer: Ohio Health Group PPO Differential	$2,498.40
Rate for Payer: Ohio Health Group PPO No Differential	$2,717.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,154.87
Rate for Payer: PHCS Commercial	$2,998.08
Rate for Payer: United Healthcare All Payer	$2,748.24

EXCISION - MALIGNANT LESION(T

Facility

$3,123.00

Service Code	HCPCS 11642
Hospital Charge Code	761T0089
Hospital Revenue Code	761
Min. Negotiated Rate	$936.90
Max. Negotiated Rate	$2,998.08
Rate for Payer: Aetna Commercial	$2,404.71
Rate for Payer: Anthem POS/PPO/Traditional	$2,435.94
Rate for Payer: Cash Price	$1,561.50
Rate for Payer: Cigna Commercial	$2,592.09
Rate for Payer: First Health Commercial	$2,966.85
Rate for Payer: Humana Commercial	$2,654.55
Rate for Payer: Medical Mutual Of Ohio HMO	$2,560.86
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,304.77
Rate for Payer: Molina Healthcare Benefit Exchange	$936.90
Rate for Payer: Ohio Health Choice Commercial	$2,748.24
Rate for Payer: Ohio Health Group HMO	$2,342.25
Rate for Payer: Ohio Health Group PPO Differential	$2,498.40
Rate for Payer: Ohio Health Group PPO No Differential	$2,717.01
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,154.87
Rate for Payer: PHCS Commercial	$2,998.08
Rate for Payer: United Healthcare All Payer	$2,748.24

EXCISION - NASAL LESION UP TO

Facility

$2,790.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$837.00
Max. Negotiated Rate	$2,678.40
Rate for Payer: Aetna Commercial	$2,148.30
Rate for Payer: Anthem POS/PPO/Traditional	$2,176.20
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cigna Commercial	$2,315.70
Rate for Payer: First Health Commercial	$2,650.50
Rate for Payer: Humana Commercial	$2,371.50
Rate for Payer: Medical Mutual Of Ohio HMO	$2,287.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,059.02
Rate for Payer: Molina Healthcare Benefit Exchange	$837.00
Rate for Payer: Ohio Health Choice Commercial	$2,455.20
Rate for Payer: Ohio Health Group HMO	$2,092.50
Rate for Payer: Ohio Health Group PPO Differential	$2,232.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,427.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,925.10
Rate for Payer: PHCS Commercial	$2,678.40
Rate for Payer: United Healthcare All Payer	$2,455.20

EXCISION - NASAL LESION UP TO

Facility

$2,790.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$2,678.40
Rate for Payer: Aetna Commercial	$2,148.30
Rate for Payer: Anthem Medicaid	$959.48
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,176.20
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cigna Commercial	$2,315.70
Rate for Payer: First Health Commercial	$2,650.50
Rate for Payer: Humana Commercial	$2,371.50
Rate for Payer: Humana KY Medicaid	$959.48
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$969.25
Rate for Payer: Medical Mutual Of Ohio HMO	$2,287.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,059.02
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$978.73
Rate for Payer: Ohio Health Choice Commercial	$2,455.20
Rate for Payer: Ohio Health Group HMO	$2,092.50
Rate for Payer: Ohio Health Group PPO Differential	$2,232.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,427.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,925.10
Rate for Payer: PHCS Commercial	$2,678.40
Rate for Payer: United Healthcare All Payer	$2,455.20

EXCISION - NASAL LESION UP TO

Professional

Both

$2,790.00

Service Code	HCPCS 11641
Hospital Charge Code	76100088
Hospital Revenue Code	761
Min. Negotiated Rate	$113.16
Max. Negotiated Rate	$1,674.00
Rate for Payer: Aetna Commercial	$221.03
Rate for Payer: Ambetter Exchange	$145.85
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$113.16
Rate for Payer: Anthem Medicaid	$130.56
Rate for Payer: Buckeye Individual/Medicaid	$145.85
Rate for Payer: Buckeye Medicare Advantage	$145.85
Rate for Payer: CareSource Just4Me Medicare	$175.02
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cigna Commercial	$297.19
Rate for Payer: Healthspan PPO	$255.48
Rate for Payer: Humana Medicaid	$130.56
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$195.60
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$145.85
Rate for Payer: Molina Healthcare Benefit Exchange	$145.85
Rate for Payer: Molina Healthcare CHIP/Medicaid	$133.17
Rate for Payer: Molina Healthcare Passport	$130.56
Rate for Payer: Multiplan PHCS	$1,674.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$189.60
Rate for Payer: UHCCP Medicaid	$118.82
Rate for Payer: Wellcare CHIP/Medicaid	$131.87
Rate for Payer: Wellcare Medicare Advantage	$145.85

EXCISION - NASAL LESION UP T(P

Professional

Both

$525.00

Service Code	HCPCS 11641
Hospital Charge Code	761P0088
Hospital Revenue Code	761
Min. Negotiated Rate	$113.16
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial	$221.03
Rate for Payer: Ambetter Exchange	$145.85
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$113.16
Rate for Payer: Anthem Medicaid	$130.56
Rate for Payer: Buckeye Individual/Medicaid	$145.85
Rate for Payer: Buckeye Medicare Advantage	$145.85
Rate for Payer: CareSource Just4Me Medicare	$175.02
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cigna Commercial	$297.19
Rate for Payer: Healthspan PPO	$255.48
Rate for Payer: Humana Medicaid	$130.56
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$195.60
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$145.85
Rate for Payer: Molina Healthcare Benefit Exchange	$145.85
Rate for Payer: Molina Healthcare CHIP/Medicaid	$133.17
Rate for Payer: Molina Healthcare Passport	$130.56
Rate for Payer: Multiplan PHCS	$315.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$189.60
Rate for Payer: UHCCP Medicaid	$118.82
Rate for Payer: Wellcare CHIP/Medicaid	$131.87
Rate for Payer: Wellcare Medicare Advantage	$145.85

EXCISION - NASAL LESION UP T(T

Facility

$2,265.00

Service Code	HCPCS 11641
Hospital Charge Code	761T0088
Hospital Revenue Code	761
Min. Negotiated Rate	$679.50
Max. Negotiated Rate	$2,174.40
Rate for Payer: Aetna Commercial	$1,744.05
Rate for Payer: Anthem POS/PPO/Traditional	$1,766.70
Rate for Payer: Cash Price	$1,132.50
Rate for Payer: Cigna Commercial	$1,879.95
Rate for Payer: First Health Commercial	$2,151.75
Rate for Payer: Humana Commercial	$1,925.25
Rate for Payer: Medical Mutual Of Ohio HMO	$1,857.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,671.57
Rate for Payer: Molina Healthcare Benefit Exchange	$679.50
Rate for Payer: Ohio Health Choice Commercial	$1,993.20
Rate for Payer: Ohio Health Group HMO	$1,698.75
Rate for Payer: Ohio Health Group PPO Differential	$1,812.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,970.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,562.85
Rate for Payer: PHCS Commercial	$2,174.40
Rate for Payer: United Healthcare All Payer	$1,993.20

EXCISION - NASAL LESION UP T(T

Facility

$2,265.00

Service Code	HCPCS 11641
Hospital Charge Code	761T0088
Hospital Revenue Code	761
Min. Negotiated Rate	$650.10
Max. Negotiated Rate	$2,174.40
Rate for Payer: Aetna Commercial	$1,744.05
Rate for Payer: Anthem Medicaid	$778.93
Rate for Payer: Anthem Medicare Advantage/PPO	$650.10
Rate for Payer: Anthem POS/PPO/Traditional	$1,766.70
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$910.14
Rate for Payer: CareSource Just4Me Medicare	$877.63
Rate for Payer: Cash Price	$1,132.50
Rate for Payer: Cash Price	$1,132.50
Rate for Payer: Cigna Commercial	$1,879.95
Rate for Payer: First Health Commercial	$2,151.75
Rate for Payer: Humana Commercial	$1,925.25
Rate for Payer: Humana KY Medicaid	$778.93
Rate for Payer: Humana Medicare Advantage	$650.10
Rate for Payer: Kentucky WC Medicaid	$786.86
Rate for Payer: Medical Mutual Of Ohio HMO	$1,857.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,671.57
Rate for Payer: Molina Healthcare Benefit Exchange	$780.12
Rate for Payer: Molina Healthcare Medicaid	$794.56
Rate for Payer: Ohio Health Choice Commercial	$1,993.20
Rate for Payer: Ohio Health Group HMO	$1,698.75
Rate for Payer: Ohio Health Group PPO Differential	$1,812.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,970.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,562.85
Rate for Payer: PHCS Commercial	$2,174.40
Rate for Payer: United Healthcare All Payer	$1,993.20

EXCISION NASAL POLYP

Facility

$350.00

Service Code	HCPCS 30110
Hospital Charge Code	76101120
Hospital Revenue Code	761
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$1,916.14
Rate for Payer: Aetna Commercial	$269.50
Rate for Payer: Anthem Medicaid	$120.36
Rate for Payer: Anthem Medicare Advantage/PPO	$1,368.67
Rate for Payer: Anthem POS/PPO/Traditional	$273.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,916.14
Rate for Payer: CareSource Just4Me Medicare	$1,847.70
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cigna Commercial	$290.50
Rate for Payer: First Health Commercial	$332.50
Rate for Payer: Humana Commercial	$297.50
Rate for Payer: Humana KY Medicaid	$120.36
Rate for Payer: Humana Medicare Advantage	$1,368.67
Rate for Payer: Kentucky WC Medicaid	$121.59
Rate for Payer: Medical Mutual Of Ohio HMO	$287.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$258.30
Rate for Payer: Molina Healthcare Benefit Exchange	$1,642.40
Rate for Payer: Molina Healthcare Medicaid	$122.78
Rate for Payer: Ohio Health Choice Commercial	$308.00
Rate for Payer: Ohio Health Group HMO	$262.50
Rate for Payer: Ohio Health Group PPO Differential	$280.00
Rate for Payer: Ohio Health Group PPO No Differential	$304.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$241.50
Rate for Payer: PHCS Commercial	$336.00
Rate for Payer: United Healthcare All Payer	$308.00

EXCISION NASAL POLYP

Facility

$350.00

Service Code	HCPCS 30110
Hospital Charge Code	76101120
Hospital Revenue Code	761
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$269.50
Rate for Payer: Anthem POS/PPO/Traditional	$273.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cigna Commercial	$290.50
Rate for Payer: First Health Commercial	$332.50
Rate for Payer: Humana Commercial	$297.50
Rate for Payer: Medical Mutual Of Ohio HMO	$287.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$258.30
Rate for Payer: Molina Healthcare Benefit Exchange	$105.00
Rate for Payer: Ohio Health Choice Commercial	$308.00
Rate for Payer: Ohio Health Group HMO	$262.50
Rate for Payer: Ohio Health Group PPO Differential	$280.00
Rate for Payer: Ohio Health Group PPO No Differential	$304.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$241.50
Rate for Payer: PHCS Commercial	$336.00
Rate for Payer: United Healthcare All Payer	$308.00

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