Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)

Facility

$2,054.81

Service Code	CPT 31237
Hospital Revenue Code	360
Min. Negotiated Rate	$1,467.72
Max. Negotiated Rate	$2,054.81
Rate for Payer: Anthem Medicare Advantage/PPO	$1,467.72
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,054.81
Rate for Payer: CareSource Just4Me Medicare	$1,981.42
Rate for Payer: Humana Medicare Advantage	$1,467.72
Rate for Payer: Molina Healthcare Benefit Exchange	$1,761.26

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE

Facility

$2,054.81

Service Code	CPT 31238
Hospital Revenue Code	360
Min. Negotiated Rate	$1,467.72
Max. Negotiated Rate	$2,054.81
Rate for Payer: Anthem Medicare Advantage/PPO	$1,467.72
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,054.81
Rate for Payer: CareSource Just4Me Medicare	$1,981.42
Rate for Payer: Humana Medicare Advantage	$1,467.72
Rate for Payer: Molina Healthcare Benefit Exchange	$1,761.26

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)

Facility

$8,286.08

Service Code	CPT 31254
Hospital Revenue Code	360
Min. Negotiated Rate	$5,918.63
Max. Negotiated Rate	$8,286.08
Rate for Payer: Anthem Medicare Advantage/PPO	$5,918.63
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,286.08
Rate for Payer: CareSource Just4Me Medicare	$7,990.15
Rate for Payer: Humana Medicare Advantage	$5,918.63
Rate for Payer: Molina Healthcare Benefit Exchange	$7,102.36

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

Facility

$8,286.08

Service Code	CPT 31253
Hospital Revenue Code	360
Min. Negotiated Rate	$5,918.63
Max. Negotiated Rate	$8,286.08
Rate for Payer: Anthem Medicare Advantage/PPO	$5,918.63
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,286.08
Rate for Payer: CareSource Just4Me Medicare	$7,990.15
Rate for Payer: Humana Medicare Advantage	$5,918.63
Rate for Payer: Molina Healthcare Benefit Exchange	$7,102.36

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY

Facility

$2,054.81

Service Code	CPT 31241
Hospital Revenue Code	360
Min. Negotiated Rate	$1,467.72
Max. Negotiated Rate	$2,054.81
Rate for Payer: Anthem Medicare Advantage/PPO	$1,467.72
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,054.81
Rate for Payer: CareSource Just4Me Medicare	$1,981.42
Rate for Payer: Humana Medicare Advantage	$1,467.72
Rate for Payer: Molina Healthcare Benefit Exchange	$1,761.26

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;

Facility

$4,533.70

Service Code	CPT 31256
Hospital Revenue Code	360
Min. Negotiated Rate	$3,238.36
Max. Negotiated Rate	$4,533.70
Rate for Payer: Anthem Medicare Advantage/PPO	$3,238.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,533.70
Rate for Payer: CareSource Just4Me Medicare	$4,371.79
Rate for Payer: Humana Medicare Advantage	$3,238.36
Rate for Payer: Molina Healthcare Benefit Exchange	$3,886.03

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS

Facility

$8,286.08

Service Code	CPT 31267
Hospital Revenue Code	360
Min. Negotiated Rate	$5,918.63
Max. Negotiated Rate	$8,286.08
Rate for Payer: Anthem Medicare Advantage/PPO	$5,918.63
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,286.08
Rate for Payer: CareSource Just4Me Medicare	$7,990.15
Rate for Payer: Humana Medicare Advantage	$5,918.63
Rate for Payer: Molina Healthcare Benefit Exchange	$7,102.36

NASAL/SINUS ENDOSCOPY SURG(P

Professional

Both

$715.00

Service Code	HCPCS 31240
Hospital Charge Code	761P1150
Hospital Revenue Code	761
Min. Negotiated Rate	$175.16
Max. Negotiated Rate	$715.00
Rate for Payer: Aetna Commercial	$244.30
Rate for Payer: Anthem Medicaid	$175.16
Rate for Payer: Buckeye Medicare Advantage	$715.00
Rate for Payer: Cash Price	$357.50
Rate for Payer: Cash Price	$357.50
Rate for Payer: Cigna Commercial	$246.29
Rate for Payer: Healthspan PPO	$206.02
Rate for Payer: Humana Medicaid	$175.16
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$209.65
Rate for Payer: Molina Healthcare CHIP/Medicaid	$178.66
Rate for Payer: Molina Healthcare Passport	$175.16
Rate for Payer: Multiplan PHCS	$429.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$500.50
Rate for Payer: UHCCP Medicaid	$250.25
Rate for Payer: Wellcare CHIP/Medicaid	$176.91

NASO/ORO GASTRIC TUBE PLCMT

Facility

$1,797.00

Service Code	HCPCS 43752
Hospital Charge Code	76101790
Hospital Revenue Code	761
Min. Negotiated Rate	$233.61
Max. Negotiated Rate	$1,725.12
Rate for Payer: Aetna Commercial	$1,383.69
Rate for Payer: Anthem Medicaid	$617.99
Rate for Payer: Anthem Medicare Advantage/PPO	$344.55
Rate for Payer: Anthem POS/PPO/Traditional	$1,401.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.37
Rate for Payer: CareSource Just4Me Medicare	$465.14
Rate for Payer: Cash Price	$898.50
Rate for Payer: Cash Price	$898.50
Rate for Payer: Cigna Commercial	$1,491.51
Rate for Payer: First Health Commercial	$1,707.15
Rate for Payer: Humana Commercial	$1,527.45
Rate for Payer: Humana KY Medicaid	$617.99
Rate for Payer: Humana Medicare Advantage	$344.55
Rate for Payer: Kentucky WC Medicaid	$624.28
Rate for Payer: Medical Mutual Of Ohio HMO	$1,473.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,326.19
Rate for Payer: Molina Healthcare Benefit Exchange	$413.46
Rate for Payer: Molina Healthcare Medicaid	$630.39
Rate for Payer: Ohio Health Choice Commercial	$1,581.36
Rate for Payer: Ohio Health Group HMO	$1,347.75
Rate for Payer: Ohio Health Group PPO Differential	$359.40
Rate for Payer: Ohio Health Group PPO No Differential	$233.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$557.07
Rate for Payer: PHCS Commercial	$1,725.12
Rate for Payer: United Healthcare All Payer	$1,581.36

NASO/ORO GASTRIC TUBE PLCMT

Facility

$1,797.00

Service Code	HCPCS 43752
Hospital Charge Code	76101790
Hospital Revenue Code	761
Min. Negotiated Rate	$233.61
Max. Negotiated Rate	$1,725.12
Rate for Payer: Aetna Commercial	$1,383.69
Rate for Payer: Anthem POS/PPO/Traditional	$1,401.66
Rate for Payer: Cash Price	$898.50
Rate for Payer: Cigna Commercial	$1,491.51
Rate for Payer: First Health Commercial	$1,707.15
Rate for Payer: Humana Commercial	$1,527.45
Rate for Payer: Medical Mutual Of Ohio HMO	$1,473.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,326.19
Rate for Payer: Molina Healthcare Benefit Exchange	$539.10
Rate for Payer: Ohio Health Choice Commercial	$1,581.36
Rate for Payer: Ohio Health Group HMO	$1,347.75
Rate for Payer: Ohio Health Group PPO Differential	$359.40
Rate for Payer: Ohio Health Group PPO No Differential	$233.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$557.07
Rate for Payer: PHCS Commercial	$1,725.12
Rate for Payer: United Healthcare All Payer	$1,581.36

NASO/ORO GASTRIC TUBE PLCMT

Facility

$586.00

Service Code	HCPCS 43752
Hospital Charge Code	45000265
Hospital Revenue Code	450
Min. Negotiated Rate	$76.18
Max. Negotiated Rate	$562.56
Rate for Payer: Aetna Commercial	$451.22
Rate for Payer: Anthem Medicaid	$201.53
Rate for Payer: Anthem Medicare Advantage/PPO	$344.55
Rate for Payer: Anthem POS/PPO/Traditional	$457.08
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.37
Rate for Payer: CareSource Just4Me Medicare	$465.14
Rate for Payer: Cash Price	$293.00
Rate for Payer: Cash Price	$293.00
Rate for Payer: Cigna Commercial	$486.38
Rate for Payer: First Health Commercial	$556.70
Rate for Payer: Humana Commercial	$498.10
Rate for Payer: Humana KY Medicaid	$201.53
Rate for Payer: Humana Medicare Advantage	$344.55
Rate for Payer: Kentucky WC Medicaid	$203.58
Rate for Payer: Medical Mutual Of Ohio HMO	$480.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$432.47
Rate for Payer: Molina Healthcare Benefit Exchange	$413.46
Rate for Payer: Molina Healthcare Medicaid	$205.57
Rate for Payer: Ohio Health Choice Commercial	$515.68
Rate for Payer: Ohio Health Group HMO	$439.50
Rate for Payer: Ohio Health Group PPO Differential	$117.20
Rate for Payer: Ohio Health Group PPO No Differential	$76.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$181.66
Rate for Payer: PHCS Commercial	$562.56
Rate for Payer: United Healthcare All Payer	$515.68

NASO/ORO GASTRIC TUBE PLCMT

Facility

$586.00

Service Code	HCPCS 43752
Hospital Charge Code	45000265
Hospital Revenue Code	450
Min. Negotiated Rate	$76.18
Max. Negotiated Rate	$562.56
Rate for Payer: Aetna Commercial	$451.22
Rate for Payer: Anthem POS/PPO/Traditional	$457.08
Rate for Payer: Cash Price	$293.00
Rate for Payer: Cigna Commercial	$486.38
Rate for Payer: First Health Commercial	$556.70
Rate for Payer: Humana Commercial	$498.10
Rate for Payer: Medical Mutual Of Ohio HMO	$480.52
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$432.47
Rate for Payer: Molina Healthcare Benefit Exchange	$175.80
Rate for Payer: Ohio Health Choice Commercial	$515.68
Rate for Payer: Ohio Health Group HMO	$439.50
Rate for Payer: Ohio Health Group PPO Differential	$117.20
Rate for Payer: Ohio Health Group PPO No Differential	$76.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$181.66
Rate for Payer: PHCS Commercial	$562.56
Rate for Payer: United Healthcare All Payer	$515.68

NASO/ORO GASTRIC TUBE PLCMT

Professional

Both

$1,797.00

Service Code	HCPCS 43752
Hospital Charge Code	76101790
Hospital Revenue Code	761
Min. Negotiated Rate	$53.14
Max. Negotiated Rate	$1,797.00
Rate for Payer: Aetna Commercial	$63.17
Rate for Payer: Anthem Medicaid	$154.78
Rate for Payer: Buckeye Medicare Advantage	$1,797.00
Rate for Payer: Cash Price	$898.50
Rate for Payer: Cash Price	$898.50
Rate for Payer: Cigna Commercial	$58.01
Rate for Payer: Healthspan PPO	$53.27
Rate for Payer: Humana Medicaid	$154.78
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$53.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$157.88
Rate for Payer: Molina Healthcare Passport	$154.78
Rate for Payer: Multiplan PHCS	$1,078.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,257.90
Rate for Payer: UHCCP Medicaid	$628.95
Rate for Payer: Wellcare CHIP/Medicaid	$156.33

NASO/ORO GASTRIC TUBE PLCMT(P

Professional

Both

$1,200.00

Service Code	HCPCS 43752
Hospital Charge Code	761P1790
Hospital Revenue Code	761
Min. Negotiated Rate	$53.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.17
Rate for Payer: Anthem Medicaid	$154.78
Rate for Payer: Buckeye Medicare Advantage	$1,200.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cigna Commercial	$58.01
Rate for Payer: Healthspan PPO	$53.27
Rate for Payer: Humana Medicaid	$154.78
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$53.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$157.88
Rate for Payer: Molina Healthcare Passport	$154.78
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$840.00
Rate for Payer: UHCCP Medicaid	$420.00
Rate for Payer: Wellcare CHIP/Medicaid	$156.33

NASO/ORO GASTRIC TUBE PLCMT(T

Facility

$597.00

Service Code	HCPCS 43752
Hospital Charge Code	761T1790
Hospital Revenue Code	761
Min. Negotiated Rate	$77.61
Max. Negotiated Rate	$573.12
Rate for Payer: Aetna Commercial	$459.69
Rate for Payer: Anthem POS/PPO/Traditional	$465.66
Rate for Payer: Cash Price	$298.50
Rate for Payer: Cigna Commercial	$495.51
Rate for Payer: First Health Commercial	$567.15
Rate for Payer: Humana Commercial	$507.45
Rate for Payer: Medical Mutual Of Ohio HMO	$489.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$440.59
Rate for Payer: Molina Healthcare Benefit Exchange	$179.10
Rate for Payer: Ohio Health Choice Commercial	$525.36
Rate for Payer: Ohio Health Group HMO	$447.75
Rate for Payer: Ohio Health Group PPO Differential	$119.40
Rate for Payer: Ohio Health Group PPO No Differential	$77.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$185.07
Rate for Payer: PHCS Commercial	$573.12
Rate for Payer: United Healthcare All Payer	$525.36

NASO/ORO GASTRIC TUBE PLCMT(T

Facility

$597.00

Service Code	HCPCS 43752
Hospital Charge Code	761T1790
Hospital Revenue Code	761
Min. Negotiated Rate	$77.61
Max. Negotiated Rate	$573.12
Rate for Payer: Aetna Commercial	$459.69
Rate for Payer: Anthem Medicaid	$205.31
Rate for Payer: Anthem Medicare Advantage/PPO	$344.55
Rate for Payer: Anthem POS/PPO/Traditional	$465.66
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$482.37
Rate for Payer: CareSource Just4Me Medicare	$465.14
Rate for Payer: Cash Price	$298.50
Rate for Payer: Cash Price	$298.50
Rate for Payer: Cigna Commercial	$495.51
Rate for Payer: First Health Commercial	$567.15
Rate for Payer: Humana Commercial	$507.45
Rate for Payer: Humana KY Medicaid	$205.31
Rate for Payer: Humana Medicare Advantage	$344.55
Rate for Payer: Kentucky WC Medicaid	$207.40
Rate for Payer: Medical Mutual Of Ohio HMO	$489.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$440.59
Rate for Payer: Molina Healthcare Benefit Exchange	$413.46
Rate for Payer: Molina Healthcare Medicaid	$209.43
Rate for Payer: Ohio Health Choice Commercial	$525.36
Rate for Payer: Ohio Health Group HMO	$447.75
Rate for Payer: Ohio Health Group PPO Differential	$119.40
Rate for Payer: Ohio Health Group PPO No Differential	$77.61
Rate for Payer: Ohio Health Group PPO SOMC Employees	$185.07
Rate for Payer: PHCS Commercial	$573.12
Rate for Payer: United Healthcare All Payer	$525.36

NASOPHARYNGOSCROPY W/ENDO

Professional

Both

$1,133.00

Service Code	HCPCS 92511
Hospital Charge Code	76102450
Hospital Revenue Code	761
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$1,133.00
Rate for Payer: Aetna Commercial	$88.09
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$24.62
Rate for Payer: Anthem Medicaid	$38.23
Rate for Payer: Buckeye Medicare Advantage	$1,133.00
Rate for Payer: Cash Price	$566.50
Rate for Payer: Cash Price	$566.50
Rate for Payer: Cigna Commercial	$229.42
Rate for Payer: Healthspan PPO	$178.96
Rate for Payer: Humana Medicaid	$38.23
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$70.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$38.99
Rate for Payer: Molina Healthcare Passport	$38.23
Rate for Payer: Multiplan PHCS	$679.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$793.10
Rate for Payer: UHCCP Medicaid	$25.85
Rate for Payer: Wellcare CHIP/Medicaid	$38.61

NASOPHARYNGOSCROPY W/ENDO

Facility

$1,133.00

Service Code	HCPCS 92511
Hospital Charge Code	76102450
Hospital Revenue Code	761
Min. Negotiated Rate	$147.29
Max. Negotiated Rate	$1,087.68
Rate for Payer: Aetna Commercial	$872.41
Rate for Payer: Anthem POS/PPO/Traditional	$883.74
Rate for Payer: Cash Price	$566.50
Rate for Payer: Cigna Commercial	$940.39
Rate for Payer: First Health Commercial	$1,076.35
Rate for Payer: Humana Commercial	$963.05
Rate for Payer: Medical Mutual Of Ohio HMO	$929.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$836.15
Rate for Payer: Molina Healthcare Benefit Exchange	$339.90
Rate for Payer: Ohio Health Choice Commercial	$997.04
Rate for Payer: Ohio Health Group HMO	$849.75
Rate for Payer: Ohio Health Group PPO Differential	$226.60
Rate for Payer: Ohio Health Group PPO No Differential	$147.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$351.23
Rate for Payer: PHCS Commercial	$1,087.68
Rate for Payer: United Healthcare All Payer	$997.04

NASOPHARYNGOSCROPY W/ENDO

Facility

$1,133.00

Service Code	HCPCS 92511
Hospital Charge Code	76102450
Hospital Revenue Code	761
Min. Negotiated Rate	$147.29
Max. Negotiated Rate	$1,087.68
Rate for Payer: Aetna Commercial	$872.41
Rate for Payer: Anthem Medicaid	$389.64
Rate for Payer: Anthem Medicare Advantage/PPO	$171.29
Rate for Payer: Anthem POS/PPO/Traditional	$883.74
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$239.81
Rate for Payer: CareSource Just4Me Medicare	$231.24
Rate for Payer: Cash Price	$566.50
Rate for Payer: Cash Price	$566.50
Rate for Payer: Cigna Commercial	$940.39
Rate for Payer: First Health Commercial	$1,076.35
Rate for Payer: Humana Commercial	$963.05
Rate for Payer: Humana KY Medicaid	$389.64
Rate for Payer: Humana Medicare Advantage	$171.29
Rate for Payer: Kentucky WC Medicaid	$393.60
Rate for Payer: Medical Mutual Of Ohio HMO	$929.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$836.15
Rate for Payer: Molina Healthcare Benefit Exchange	$205.55
Rate for Payer: Molina Healthcare Medicaid	$397.46
Rate for Payer: Ohio Health Choice Commercial	$997.04
Rate for Payer: Ohio Health Group HMO	$849.75
Rate for Payer: Ohio Health Group PPO Differential	$226.60
Rate for Payer: Ohio Health Group PPO No Differential	$147.29
Rate for Payer: Ohio Health Group PPO SOMC Employees	$351.23
Rate for Payer: PHCS Commercial	$1,087.68
Rate for Payer: United Healthcare All Payer	$997.04

NASOPHARYNGOSCROPY W/ENDO(P

Professional

Both

$750.00

Service Code	HCPCS 92511
Hospital Charge Code	761P2450
Hospital Revenue Code	761
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$750.00
Rate for Payer: Aetna Commercial	$88.09
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$24.62
Rate for Payer: Anthem Medicaid	$38.23
Rate for Payer: Buckeye Medicare Advantage	$750.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cigna Commercial	$229.42
Rate for Payer: Healthspan PPO	$178.96
Rate for Payer: Humana Medicaid	$38.23
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$70.14
Rate for Payer: Molina Healthcare CHIP/Medicaid	$38.99
Rate for Payer: Molina Healthcare Passport	$38.23
Rate for Payer: Multiplan PHCS	$450.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$525.00
Rate for Payer: UHCCP Medicaid	$25.85
Rate for Payer: Wellcare CHIP/Medicaid	$38.61

NASOPHARYNGOSCROPY W/ENDO(T

Facility

$383.00

Service Code	HCPCS 92511
Hospital Charge Code	761T2450
Hospital Revenue Code	761
Min. Negotiated Rate	$49.79
Max. Negotiated Rate	$367.68
Rate for Payer: Aetna Commercial	$294.91
Rate for Payer: Anthem POS/PPO/Traditional	$298.74
Rate for Payer: Cash Price	$191.50
Rate for Payer: Cigna Commercial	$317.89
Rate for Payer: First Health Commercial	$363.85
Rate for Payer: Humana Commercial	$325.55
Rate for Payer: Medical Mutual Of Ohio HMO	$314.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$282.65
Rate for Payer: Molina Healthcare Benefit Exchange	$114.90
Rate for Payer: Ohio Health Choice Commercial	$337.04
Rate for Payer: Ohio Health Group HMO	$287.25
Rate for Payer: Ohio Health Group PPO Differential	$76.60
Rate for Payer: Ohio Health Group PPO No Differential	$49.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$118.73
Rate for Payer: PHCS Commercial	$367.68
Rate for Payer: United Healthcare All Payer	$337.04

NASOPHARYNGOSCROPY W/ENDO(T

Facility

$383.00

Service Code	HCPCS 92511
Hospital Charge Code	761T2450
Hospital Revenue Code	761
Min. Negotiated Rate	$49.79
Max. Negotiated Rate	$367.68
Rate for Payer: Aetna Commercial	$294.91
Rate for Payer: Anthem Medicaid	$131.71
Rate for Payer: Anthem Medicare Advantage/PPO	$171.29
Rate for Payer: Anthem POS/PPO/Traditional	$298.74
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$239.81
Rate for Payer: CareSource Just4Me Medicare	$231.24
Rate for Payer: Cash Price	$191.50
Rate for Payer: Cash Price	$191.50
Rate for Payer: Cigna Commercial	$317.89
Rate for Payer: First Health Commercial	$363.85
Rate for Payer: Humana Commercial	$325.55
Rate for Payer: Humana KY Medicaid	$131.71
Rate for Payer: Humana Medicare Advantage	$171.29
Rate for Payer: Kentucky WC Medicaid	$133.05
Rate for Payer: Medical Mutual Of Ohio HMO	$314.06
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$282.65
Rate for Payer: Molina Healthcare Benefit Exchange	$205.55
Rate for Payer: Molina Healthcare Medicaid	$134.36
Rate for Payer: Ohio Health Choice Commercial	$337.04
Rate for Payer: Ohio Health Group HMO	$287.25
Rate for Payer: Ohio Health Group PPO Differential	$76.60
Rate for Payer: Ohio Health Group PPO No Differential	$49.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$118.73
Rate for Payer: PHCS Commercial	$367.68
Rate for Payer: United Healthcare All Payer	$337.04

NASOPHARYNX BX

Facility

$4,124.36

Service Code	HCPCS 42804
Hospital Charge Code	76101700
Hospital Revenue Code	761
Min. Negotiated Rate	$536.17
Max. Negotiated Rate	$3,959.39
Rate for Payer: Aetna Commercial	$3,175.76
Rate for Payer: Anthem Medicaid	$1,418.37
Rate for Payer: Anthem Medicare Advantage/PPO	$2,784.17
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.00
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	$2,062.18
Rate for Payer: Cash Price	$2,062.18
Rate for Payer: Cigna Commercial	$3,423.22
Rate for Payer: First Health Commercial	$3,918.14
Rate for Payer: Humana Commercial	$3,505.71
Rate for Payer: Humana KY Medicaid	$1,418.37
Rate for Payer: Humana Medicare Advantage	$2,784.17
Rate for Payer: Kentucky WC Medicaid	$1,432.80
Rate for Payer: Medical Mutual Of Ohio HMO	$3,381.98
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,043.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,341.00
Rate for Payer: Molina Healthcare Medicaid	$1,446.83
Rate for Payer: Ohio Health Choice Commercial	$3,629.44
Rate for Payer: Ohio Health Group HMO	$3,093.27
Rate for Payer: Ohio Health Group PPO Differential	$824.87
Rate for Payer: Ohio Health Group PPO No Differential	$536.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.55
Rate for Payer: PHCS Commercial	$3,959.39
Rate for Payer: United Healthcare All Payer	$3,629.44

NASOPHARYNX BX

Facility

$4,124.36

Service Code	HCPCS 42804
Hospital Charge Code	76101700
Hospital Revenue Code	761
Min. Negotiated Rate	$536.17
Max. Negotiated Rate	$3,959.39
Rate for Payer: Aetna Commercial	$3,175.76
Rate for Payer: Anthem POS/PPO/Traditional	$3,217.00
Rate for Payer: Cash Price	$2,062.18
Rate for Payer: Cigna Commercial	$3,423.22
Rate for Payer: First Health Commercial	$3,918.14
Rate for Payer: Humana Commercial	$3,505.71
Rate for Payer: Medical Mutual Of Ohio HMO	$3,381.98
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,043.78
Rate for Payer: Molina Healthcare Benefit Exchange	$1,237.31
Rate for Payer: Ohio Health Choice Commercial	$3,629.44
Rate for Payer: Ohio Health Group HMO	$3,093.27
Rate for Payer: Ohio Health Group PPO Differential	$824.87
Rate for Payer: Ohio Health Group PPO No Differential	$536.17
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,278.55
Rate for Payer: PHCS Commercial	$3,959.39
Rate for Payer: United Healthcare All Payer	$3,629.44

NASOPHARYNX BX

Professional

Both

$4,124.36

Service Code	HCPCS 42804
Hospital Charge Code	76101700
Hospital Revenue Code	761
Min. Negotiated Rate	$67.31
Max. Negotiated Rate	$4,124.36
Rate for Payer: Aetna Commercial	$163.89
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$73.56
Rate for Payer: Anthem Medicaid	$67.31
Rate for Payer: Buckeye Medicare Advantage	$4,124.36
Rate for Payer: Cash Price	$2,062.18
Rate for Payer: Cash Price	$2,062.18
Rate for Payer: Cigna Commercial	$167.06
Rate for Payer: Healthspan PPO	$229.84
Rate for Payer: Humana Medicaid	$67.31
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$146.98
Rate for Payer: Molina Healthcare CHIP/Medicaid	$68.66
Rate for Payer: Molina Healthcare Passport	$67.31
Rate for Payer: Multiplan PHCS	$2,474.62
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,887.05
Rate for Payer: UHCCP Medicaid	$77.24
Rate for Payer: Wellcare CHIP/Medicaid	$67.98

Know your out-of-pocket cost for care.

All Charges