Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 21014
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, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER

Facility

$2,095.90

Service Code	CPT 21012
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, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 28039
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, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$2,095.90

Service Code	CPT 25071
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, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$2,095.90

Service Code	CPT 25075
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, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 27632
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, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 21552
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, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$2,095.90

Service Code	CPT 21555
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, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 21554
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, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM

Facility

$3,702.27

Service Code	CPT 21556
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, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 27043
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, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$3,702.27

Service Code	CPT 27047
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, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$2,095.90

Service Code	CPT 23071
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, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM

Facility

$3,702.27

Service Code	CPT 23076
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, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 27337
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, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$2,095.90

Service Code	CPT 27327
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, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 27339
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, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 24071
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, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$2,095.90

Service Code	CPT 24075
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, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER

Facility

$3,702.27

Service Code	CPT 24073
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 VAG CUFF ENDOMETRIOMA

Facility

$2,500.00

Service Code	HCPCS 58999
Hospital Charge Code	76102267
Hospital Revenue Code	761
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$2,400.00
Rate for Payer: Aetna Commercial	$1,925.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,950.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Cigna Commercial	$2,075.00
Rate for Payer: First Health Commercial	$2,375.00
Rate for Payer: Humana Commercial	$2,125.00
Rate for Payer: Medical Mutual Of Ohio HMO	$2,050.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,845.00
Rate for Payer: Molina Healthcare Benefit Exchange	$750.00
Rate for Payer: Ohio Health Choice Commercial	$2,200.00
Rate for Payer: Ohio Health Group HMO	$1,875.00
Rate for Payer: Ohio Health Group PPO Differential	$2,000.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,175.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,725.00
Rate for Payer: PHCS Commercial	$2,400.00
Rate for Payer: United Healthcare All Payer	$2,200.00

EXCISION VAG CUFF ENDOMETRIOMA

Facility

$2,500.00

Service Code	HCPCS 58999
Hospital Charge Code	76102267
Hospital Revenue Code	761
Min. Negotiated Rate	$185.88
Max. Negotiated Rate	$2,400.00
Rate for Payer: Aetna Commercial	$1,925.00
Rate for Payer: Anthem Medicaid	$859.75
Rate for Payer: Anthem Medicare Advantage/PPO	$185.88
Rate for Payer: Anthem POS/PPO/Traditional	$1,950.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$260.23
Rate for Payer: CareSource Just4Me Medicare	$250.94
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Cigna Commercial	$2,075.00
Rate for Payer: First Health Commercial	$2,375.00
Rate for Payer: Humana Commercial	$2,125.00
Rate for Payer: Humana KY Medicaid	$859.75
Rate for Payer: Humana Medicare Advantage	$185.88
Rate for Payer: Kentucky WC Medicaid	$868.50
Rate for Payer: Medical Mutual Of Ohio HMO	$2,050.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,845.00
Rate for Payer: Molina Healthcare Benefit Exchange	$223.06
Rate for Payer: Molina Healthcare Medicaid	$877.00
Rate for Payer: Ohio Health Choice Commercial	$2,200.00
Rate for Payer: Ohio Health Group HMO	$1,875.00
Rate for Payer: Ohio Health Group PPO Differential	$2,000.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,175.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,725.00
Rate for Payer: PHCS Commercial	$2,400.00
Rate for Payer: United Healthcare All Payer	$2,200.00

EXCISION VAG CUFF ENDOMETRIOMA

Professional

Both

$2,500.00

Service Code	HCPCS 58999
Hospital Charge Code	76102267
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,750.00
Rate for Payer: Anthem Medicaid	$741.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$741.00
Rate for Payer: Molina Healthcare CHIP/Medicaid	$755.82
Rate for Payer: Molina Healthcare Passport	$741.00
Rate for Payer: Multiplan PHCS	$1,500.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,750.00
Rate for Payer: UHCCP Medicaid	$875.00
Rate for Payer: Wellcare CHIP/Medicaid	$748.41

EXCISION VAG CUFF ENDOMETRIOMA

Professional

Both

$2,500.00

Service Code	HCPCS 58999
Hospital Charge Code	761P2267
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,750.00
Rate for Payer: Anthem Medicaid	$741.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Cash Price	$1,250.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$741.00
Rate for Payer: Molina Healthcare CHIP/Medicaid	$755.82
Rate for Payer: Molina Healthcare Passport	$741.00
Rate for Payer: Multiplan PHCS	$1,500.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,750.00
Rate for Payer: UHCCP Medicaid	$875.00
Rate for Payer: Wellcare CHIP/Medicaid	$748.41

EXCISION VAGINAL SEPTUM

Professional

Both

$425.00

Service Code	HCPCS 57130
Hospital Charge Code	76103005
Hospital Revenue Code	761
Min. Negotiated Rate	$121.89
Max. Negotiated Rate	$261.58
Rate for Payer: Aetna Commercial	$242.86
Rate for Payer: Ambetter Exchange	$162.86
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$121.89
Rate for Payer: Anthem Medicaid	$154.06
Rate for Payer: Buckeye Individual/Medicaid	$162.86
Rate for Payer: Buckeye Medicare Advantage	$162.86
Rate for Payer: CareSource Just4Me Medicare	$195.43
Rate for Payer: Cash Price	$212.50
Rate for Payer: Cash Price	$212.50
Rate for Payer: Cigna Commercial	$236.11
Rate for Payer: Healthspan PPO	$261.58
Rate for Payer: Humana Medicaid	$154.06
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$206.88
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$162.86
Rate for Payer: Molina Healthcare Benefit Exchange	$162.86
Rate for Payer: Molina Healthcare CHIP/Medicaid	$157.14
Rate for Payer: Molina Healthcare Passport	$154.06
Rate for Payer: Multiplan PHCS	$255.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$211.72
Rate for Payer: UHCCP Medicaid	$127.98
Rate for Payer: Wellcare CHIP/Medicaid	$155.60
Rate for Payer: Wellcare Medicare Advantage	$162.86

Know your out-of-pocket cost for care.

All Charges