Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ENDO MODEL MODUL FMR MD LFT

Facility

$32,496.20

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,224.51
Max. Negotiated Rate	$31,196.35
Rate for Payer: Aetna Commercial	$25,022.07
Rate for Payer: Anthem POS/PPO/Traditional	$25,347.04
Rate for Payer: Cash Price	$16,248.10
Rate for Payer: Cigna Commercial	$26,971.85
Rate for Payer: First Health Commercial	$30,871.39
Rate for Payer: Humana Commercial	$27,621.77
Rate for Payer: Medical Mutual Of Ohio HMO	$26,646.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$23,982.20
Rate for Payer: Molina Healthcare Benefit Exchange	$9,748.86
Rate for Payer: Ohio Health Choice Commercial	$28,596.66
Rate for Payer: Ohio Health Group HMO	$24,372.15
Rate for Payer: Ohio Health Group PPO Differential	$6,499.24
Rate for Payer: Ohio Health Group PPO No Differential	$4,224.51
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,073.82
Rate for Payer: PHCS Commercial	$31,196.35
Rate for Payer: United Healthcare All Payer	$28,596.66

ENDO MODEL MODUL FMR MD LFT

Facility

$32,496.20

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$4,224.51
Max. Negotiated Rate	$31,196.35
Rate for Payer: Aetna Commercial	$25,022.07
Rate for Payer: Anthem Medicaid	$11,175.44
Rate for Payer: Anthem POS/PPO/Traditional	$25,347.04
Rate for Payer: Cash Price	$16,248.10
Rate for Payer: Cigna Commercial	$26,971.85
Rate for Payer: First Health Commercial	$30,871.39
Rate for Payer: Humana Commercial	$27,621.77
Rate for Payer: Humana KY Medicaid	$11,175.44
Rate for Payer: Kentucky WC Medicaid	$11,289.18
Rate for Payer: Medical Mutual Of Ohio HMO	$26,646.88
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$23,982.20
Rate for Payer: Molina Healthcare Benefit Exchange	$9,748.86
Rate for Payer: Molina Healthcare Medicaid	$11,399.67
Rate for Payer: Ohio Health Choice Commercial	$28,596.66
Rate for Payer: Ohio Health Group HMO	$24,372.15
Rate for Payer: Ohio Health Group PPO Differential	$6,499.24
Rate for Payer: Ohio Health Group PPO No Differential	$4,224.51
Rate for Payer: Ohio Health Group PPO SOMC Employees	$10,073.82
Rate for Payer: PHCS Commercial	$31,196.35
Rate for Payer: United Healthcare All Payer	$28,596.66

ENDO MODULAR STEM 120MM*14MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem Medicaid	$4,390.95
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Humana KY Medicaid	$4,390.95
Rate for Payer: Kentucky WC Medicaid	$4,435.64
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Molina Healthcare Medicaid	$4,479.05
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDO MODULAR STEM 120MM*14MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDO MODULAR STEM 120MM*16MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem Medicaid	$4,390.95
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Humana KY Medicaid	$4,390.95
Rate for Payer: Kentucky WC Medicaid	$4,435.64
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Molina Healthcare Medicaid	$4,479.05
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDO MODULAR STEM 120MM*16MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDO MODULAR STEM 160MM*16MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem Medicaid	$4,390.95
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Humana KY Medicaid	$4,390.95
Rate for Payer: Kentucky WC Medicaid	$4,435.64
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Molina Healthcare Medicaid	$4,479.05
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDO MODULAR STEM 160MM*16MM

Facility

$12,768.10

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,659.85
Max. Negotiated Rate	$12,257.38
Rate for Payer: Aetna Commercial	$9,831.44
Rate for Payer: Anthem POS/PPO/Traditional	$9,959.12
Rate for Payer: Cash Price	$6,384.05
Rate for Payer: Cigna Commercial	$10,597.52
Rate for Payer: First Health Commercial	$12,129.70
Rate for Payer: Humana Commercial	$10,852.88
Rate for Payer: Medical Mutual Of Ohio HMO	$10,469.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$9,422.86
Rate for Payer: Molina Healthcare Benefit Exchange	$3,830.43
Rate for Payer: Ohio Health Choice Commercial	$11,235.93
Rate for Payer: Ohio Health Group HMO	$9,576.08
Rate for Payer: Ohio Health Group PPO Differential	$2,553.62
Rate for Payer: Ohio Health Group PPO No Differential	$1,659.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,958.11
Rate for Payer: PHCS Commercial	$12,257.38
Rate for Payer: United Healthcare All Payer	$11,235.93

ENDOMYOCARDIAL BIOPSY

Facility

$1,108.00

Service Code	HCPCS 93505
Hospital Charge Code	48000096
Hospital Revenue Code	480
Min. Negotiated Rate	$144.04
Max. Negotiated Rate	$1,063.68
Rate for Payer: Aetna Commercial	$853.16
Rate for Payer: Anthem POS/PPO/Traditional	$864.24
Rate for Payer: Cash Price	$554.00
Rate for Payer: Cigna Commercial	$919.64
Rate for Payer: First Health Commercial	$1,052.60
Rate for Payer: Humana Commercial	$941.80
Rate for Payer: Medical Mutual Of Ohio HMO	$908.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$817.70
Rate for Payer: Molina Healthcare Benefit Exchange	$332.40
Rate for Payer: Ohio Health Choice Commercial	$975.04
Rate for Payer: Ohio Health Group HMO	$831.00
Rate for Payer: Ohio Health Group PPO Differential	$221.60
Rate for Payer: Ohio Health Group PPO No Differential	$144.04
Rate for Payer: Ohio Health Group PPO SOMC Employees	$343.48
Rate for Payer: PHCS Commercial	$1,063.68
Rate for Payer: United Healthcare All Payer	$975.04

ENDOMYOCARDIAL BIOPSY

Facility

$1,108.00

Service Code	HCPCS 93505
Hospital Charge Code	48000096
Hospital Revenue Code	480
Min. Negotiated Rate	$144.04
Max. Negotiated Rate	$3,858.95
Rate for Payer: Aetna Commercial	$853.16
Rate for Payer: Anthem Medicaid	$381.04
Rate for Payer: Anthem Medicare Advantage/PPO	$2,756.39
Rate for Payer: Anthem POS/PPO/Traditional	$864.24
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$3,858.95
Rate for Payer: CareSource Just4Me Medicare	$3,721.13
Rate for Payer: Cash Price	$554.00
Rate for Payer: Cash Price	$554.00
Rate for Payer: Cigna Commercial	$919.64
Rate for Payer: First Health Commercial	$1,052.60
Rate for Payer: Humana Commercial	$941.80
Rate for Payer: Humana KY Medicaid	$381.04
Rate for Payer: Humana Medicare Advantage	$2,756.39
Rate for Payer: Kentucky WC Medicaid	$384.92
Rate for Payer: Medical Mutual Of Ohio HMO	$908.56
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$817.70
Rate for Payer: Molina Healthcare Benefit Exchange	$3,307.67
Rate for Payer: Molina Healthcare Medicaid	$388.69
Rate for Payer: Ohio Health Choice Commercial	$975.04
Rate for Payer: Ohio Health Group HMO	$831.00
Rate for Payer: Ohio Health Group PPO Differential	$221.60
Rate for Payer: Ohio Health Group PPO No Differential	$144.04
Rate for Payer: Ohio Health Group PPO SOMC Employees	$343.48
Rate for Payer: PHCS Commercial	$1,063.68
Rate for Payer: United Healthcare All Payer	$975.04

ENDOPLEDGE COR SINUS CATHETER

Facility

$10,873.75

Service Code	HCPCS C2628
Hospital Charge Code	27000014
Hospital Revenue Code	272
Min. Negotiated Rate	$1,413.59
Max. Negotiated Rate	$10,438.80
Rate for Payer: Aetna Commercial	$8,372.79
Rate for Payer: Anthem POS/PPO/Traditional	$8,481.52
Rate for Payer: Cash Price	$5,436.88
Rate for Payer: Cigna Commercial	$9,025.21
Rate for Payer: First Health Commercial	$10,330.06
Rate for Payer: Humana Commercial	$9,242.69
Rate for Payer: Medical Mutual Of Ohio HMO	$8,916.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,024.83
Rate for Payer: Molina Healthcare Benefit Exchange	$3,262.12
Rate for Payer: Ohio Health Choice Commercial	$9,568.90
Rate for Payer: Ohio Health Group HMO	$8,155.31
Rate for Payer: Ohio Health Group PPO Differential	$2,174.75
Rate for Payer: Ohio Health Group PPO No Differential	$1,413.59
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,370.86
Rate for Payer: PHCS Commercial	$10,438.80
Rate for Payer: United Healthcare All Payer	$9,568.90

ENDOPLEDGE COR SINUS CATHETER

Facility

$10,873.75

Service Code	HCPCS C2628
Hospital Charge Code	27000014
Hospital Revenue Code	272
Min. Negotiated Rate	$1,413.59
Max. Negotiated Rate	$10,438.80
Rate for Payer: Aetna Commercial	$8,372.79
Rate for Payer: Anthem Medicaid	$3,739.48
Rate for Payer: Anthem POS/PPO/Traditional	$8,481.52
Rate for Payer: Cash Price	$5,436.88
Rate for Payer: Cigna Commercial	$9,025.21
Rate for Payer: First Health Commercial	$10,330.06
Rate for Payer: Humana Commercial	$9,242.69
Rate for Payer: Humana KY Medicaid	$3,739.48
Rate for Payer: Kentucky WC Medicaid	$3,777.54
Rate for Payer: Medical Mutual Of Ohio HMO	$8,916.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$8,024.83
Rate for Payer: Molina Healthcare Benefit Exchange	$3,262.12
Rate for Payer: Molina Healthcare Medicaid	$3,814.51
Rate for Payer: Ohio Health Choice Commercial	$9,568.90
Rate for Payer: Ohio Health Group HMO	$8,155.31
Rate for Payer: Ohio Health Group PPO Differential	$2,174.75
Rate for Payer: Ohio Health Group PPO No Differential	$1,413.59
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,370.86
Rate for Payer: PHCS Commercial	$10,438.80
Rate for Payer: United Healthcare All Payer	$9,568.90

ENDOSCOPIC INJECTION/IMPLANT

Facility

$900.00

Service Code	HCPCS 51715
Hospital Charge Code	76102872
Hospital Revenue Code	761
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$4,220.54
Rate for Payer: Aetna Commercial	$693.00
Rate for Payer: Anthem Medicaid	$309.51
Rate for Payer: Anthem Medicare Advantage/PPO	$3,014.67
Rate for Payer: Anthem POS/PPO/Traditional	$702.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,220.54
Rate for Payer: CareSource Just4Me Medicare	$4,069.80
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial	$747.00
Rate for Payer: First Health Commercial	$855.00
Rate for Payer: Humana Commercial	$765.00
Rate for Payer: Humana KY Medicaid	$309.51
Rate for Payer: Humana Medicare Advantage	$3,014.67
Rate for Payer: Kentucky WC Medicaid	$312.66
Rate for Payer: Medical Mutual Of Ohio HMO	$738.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$664.20
Rate for Payer: Molina Healthcare Benefit Exchange	$3,617.60
Rate for Payer: Molina Healthcare Medicaid	$315.72
Rate for Payer: Ohio Health Choice Commercial	$792.00
Rate for Payer: Ohio Health Group HMO	$675.00
Rate for Payer: Ohio Health Group PPO Differential	$180.00
Rate for Payer: Ohio Health Group PPO No Differential	$117.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$279.00
Rate for Payer: PHCS Commercial	$864.00
Rate for Payer: United Healthcare All Payer	$792.00

ENDOSCOPIC INJECTION/IMPLANT

Professional

Both

$900.00

Service Code	HCPCS 51715
Hospital Charge Code	76102872
Hospital Revenue Code	761
Min. Negotiated Rate	$109.27
Max. Negotiated Rate	$900.00
Rate for Payer: Aetna Commercial	$328.04
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$109.27
Rate for Payer: Anthem Medicaid	$187.38
Rate for Payer: Buckeye Medicare Advantage	$900.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial	$294.71
Rate for Payer: Healthspan PPO	$373.99
Rate for Payer: Humana Medicaid	$187.38
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$272.16
Rate for Payer: Molina Healthcare CHIP/Medicaid	$191.13
Rate for Payer: Molina Healthcare Passport	$187.38
Rate for Payer: Multiplan PHCS	$540.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$630.00
Rate for Payer: UHCCP Medicaid	$114.73
Rate for Payer: Wellcare CHIP/Medicaid	$189.25

ENDOSCOPIC INJECTION/IMPLANT

Facility

$900.00

Service Code	HCPCS 51715
Hospital Charge Code	76102872
Hospital Revenue Code	761
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$864.00
Rate for Payer: Aetna Commercial	$693.00
Rate for Payer: Anthem POS/PPO/Traditional	$702.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial	$747.00
Rate for Payer: First Health Commercial	$855.00
Rate for Payer: Humana Commercial	$765.00
Rate for Payer: Medical Mutual Of Ohio HMO	$738.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$664.20
Rate for Payer: Molina Healthcare Benefit Exchange	$270.00
Rate for Payer: Ohio Health Choice Commercial	$792.00
Rate for Payer: Ohio Health Group HMO	$675.00
Rate for Payer: Ohio Health Group PPO Differential	$180.00
Rate for Payer: Ohio Health Group PPO No Differential	$117.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$279.00
Rate for Payer: PHCS Commercial	$864.00
Rate for Payer: United Healthcare All Payer	$792.00

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK

Facility

$4,220.54

Service Code	CPT 51715
Hospital Revenue Code	360
Min. Negotiated Rate	$3,014.67
Max. Negotiated Rate	$4,220.54
Rate for Payer: Anthem Medicare Advantage/PPO	$3,014.67
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,220.54
Rate for Payer: CareSource Just4Me Medicare	$4,069.80
Rate for Payer: Humana Medicare Advantage	$3,014.67
Rate for Payer: Molina Healthcare Benefit Exchange	$3,617.60

ENDOSCOPIC PANCREATOSCOPY

Professional

Both

$525.00

Service Code	HCPCS 43273
Hospital Charge Code	76101758
Hospital Revenue Code	761
Min. Negotiated Rate	$103.25
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$198.52
Rate for Payer: Anthem Medicaid	$103.25
Rate for Payer: Buckeye Medicare Advantage	$525.00
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cigna Commercial	$200.88
Rate for Payer: Healthspan PPO	$167.41
Rate for Payer: Humana Medicaid	$103.25
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$168.07
Rate for Payer: Molina Healthcare CHIP/Medicaid	$105.32
Rate for Payer: Molina Healthcare Passport	$103.25
Rate for Payer: Multiplan PHCS	$315.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$367.50
Rate for Payer: UHCCP Medicaid	$183.75
Rate for Payer: Wellcare CHIP/Medicaid	$104.28

ENDOSCOPIC PANCREATOSCOPY

Facility

$525.00

Service Code	HCPCS 43273
Hospital Charge Code	76101758
Hospital Revenue Code	761
Min. Negotiated Rate	$68.25
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$404.25
Rate for Payer: Anthem POS/PPO/Traditional	$409.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cigna Commercial	$435.75
Rate for Payer: First Health Commercial	$498.75
Rate for Payer: Humana Commercial	$446.25
Rate for Payer: Medical Mutual Of Ohio HMO	$430.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$387.45
Rate for Payer: Molina Healthcare Benefit Exchange	$157.50
Rate for Payer: Ohio Health Choice Commercial	$462.00
Rate for Payer: Ohio Health Group HMO	$393.75
Rate for Payer: Ohio Health Group PPO Differential	$105.00
Rate for Payer: Ohio Health Group PPO No Differential	$68.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$162.75
Rate for Payer: PHCS Commercial	$504.00
Rate for Payer: United Healthcare All Payer	$462.00

ENDOSCOPIC PANCREATOSCOPY

Facility

$525.00

Service Code	HCPCS 43273
Hospital Charge Code	76101758
Hospital Revenue Code	761
Min. Negotiated Rate	$68.25
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$404.25
Rate for Payer: Anthem Medicaid	$180.55
Rate for Payer: Anthem POS/PPO/Traditional	$409.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cigna Commercial	$435.75
Rate for Payer: First Health Commercial	$498.75
Rate for Payer: Humana Commercial	$446.25
Rate for Payer: Humana KY Medicaid	$180.55
Rate for Payer: Kentucky WC Medicaid	$182.38
Rate for Payer: Medical Mutual Of Ohio HMO	$430.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$387.45
Rate for Payer: Molina Healthcare Benefit Exchange	$157.50
Rate for Payer: Molina Healthcare Medicaid	$184.17
Rate for Payer: Ohio Health Choice Commercial	$462.00
Rate for Payer: Ohio Health Group HMO	$393.75
Rate for Payer: Ohio Health Group PPO Differential	$105.00
Rate for Payer: Ohio Health Group PPO No Differential	$68.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$162.75
Rate for Payer: PHCS Commercial	$504.00
Rate for Payer: United Healthcare All Payer	$462.00

ENDOSCOPIC PANCREATOSCOPY(P

Professional

Both

$525.00

Service Code	HCPCS 43273
Hospital Charge Code	761P1758
Hospital Revenue Code	761
Min. Negotiated Rate	$103.25
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$198.52
Rate for Payer: Anthem Medicaid	$103.25
Rate for Payer: Buckeye Medicare Advantage	$525.00
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cash Price	$262.50
Rate for Payer: Cigna Commercial	$200.88
Rate for Payer: Healthspan PPO	$167.41
Rate for Payer: Humana Medicaid	$103.25
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$168.07
Rate for Payer: Molina Healthcare CHIP/Medicaid	$105.32
Rate for Payer: Molina Healthcare Passport	$103.25
Rate for Payer: Multiplan PHCS	$315.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$367.50
Rate for Payer: UHCCP Medicaid	$183.75
Rate for Payer: Wellcare CHIP/Medicaid	$104.28

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$4,636.52

Service Code	CPT 43260
Hospital Revenue Code	360
Min. Negotiated Rate	$3,311.80
Max. Negotiated Rate	$4,636.52
Rate for Payer: Anthem Medicare Advantage/PPO	$3,311.80
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,636.52
Rate for Payer: CareSource Just4Me Medicare	$4,470.93
Rate for Payer: Humana Medicare Advantage	$3,311.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,974.16

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$4,636.52

Service Code	CPT 43261
Hospital Revenue Code	360
Min. Negotiated Rate	$3,311.80
Max. Negotiated Rate	$4,636.52
Rate for Payer: Anthem Medicare Advantage/PPO	$3,311.80
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,636.52
Rate for Payer: CareSource Just4Me Medicare	$4,470.93
Rate for Payer: Humana Medicare Advantage	$3,311.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,974.16

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT

Facility

$6,899.82

Service Code	CPT 43274
Hospital Revenue Code	360
Min. Negotiated Rate	$4,928.44
Max. Negotiated Rate	$6,899.82
Rate for Payer: Anthem Medicare Advantage/PPO	$4,928.44
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,899.82
Rate for Payer: CareSource Just4Me Medicare	$6,653.39
Rate for Payer: Humana Medicare Advantage	$4,928.44
Rate for Payer: Molina Healthcare Benefit Exchange	$5,914.13

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED

Facility

$6,899.82

Service Code	CPT 43276
Hospital Revenue Code	360
Min. Negotiated Rate	$4,928.44
Max. Negotiated Rate	$6,899.82
Rate for Payer: Anthem Medicare Advantage/PPO	$4,928.44
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,899.82
Rate for Payer: CareSource Just4Me Medicare	$6,653.39
Rate for Payer: Humana Medicare Advantage	$4,928.44
Rate for Payer: Molina Healthcare Benefit Exchange	$5,914.13

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S)

Facility

$4,636.52

Service Code	CPT 43264
Hospital Revenue Code	360
Min. Negotiated Rate	$3,311.80
Max. Negotiated Rate	$4,636.52
Rate for Payer: Anthem Medicare Advantage/PPO	$3,311.80
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,636.52
Rate for Payer: CareSource Just4Me Medicare	$4,470.93
Rate for Payer: Humana Medicare Advantage	$3,311.80
Rate for Payer: Molina Healthcare Benefit Exchange	$3,974.16

Know your out-of-pocket cost for care.

All Charges