Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)

Facility

$2,303.66

Service Code	CPT 43245
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.47
Max. Negotiated Rate	$2,303.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

Facility

$2,303.66

Service Code	CPT 43246
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.47
Max. Negotiated Rate	$2,303.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE

Facility

$1,097.45

Service Code	CPT 43236
Hospital Revenue Code	360
Min. Negotiated Rate	$783.89
Max. Negotiated Rate	$1,097.45
Rate for Payer: Anthem Medicare Advantage/PPO	$783.89
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,097.45
Rate for Payer: CareSource Just4Me Medicare	$1,058.25
Rate for Payer: Humana Medicare Advantage	$783.89
Rate for Payer: Molina Healthcare Benefit Exchange	$940.67

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ESOPHAGOGASTRIC FUNDOPLASTY, PARTIAL OR COMPLETE, INCLUDES DUODENOSCOPY WHEN PERFORMED

Facility

$12,462.13

Service Code	CPT 43210
Hospital Revenue Code	360
Min. Negotiated Rate	$8,901.52
Max. Negotiated Rate	$12,462.13
Rate for Payer: Anthem Medicare Advantage/PPO	$8,901.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,462.13
Rate for Payer: CareSource Just4Me Medicare	$12,017.05
Rate for Payer: Humana Medicare Advantage	$8,901.52
Rate for Payer: Molina Healthcare Benefit Exchange	$10,681.82

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE

Facility

$1,097.45

Service Code	CPT 43248
Hospital Revenue Code	360
Min. Negotiated Rate	$783.89
Max. Negotiated Rate	$1,097.45
Rate for Payer: Anthem Medicare Advantage/PPO	$783.89
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,097.45
Rate for Payer: CareSource Just4Me Medicare	$1,058.25
Rate for Payer: Humana Medicare Advantage	$783.89
Rate for Payer: Molina Healthcare Benefit Exchange	$940.67

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)

Facility

$6,899.82

Service Code	CPT 43266
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

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)

Facility

$1,097.45

Service Code	CPT 43247
Hospital Revenue Code	360
Min. Negotiated Rate	$783.89
Max. Negotiated Rate	$1,097.45
Rate for Payer: Anthem Medicare Advantage/PPO	$783.89
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,097.45
Rate for Payer: CareSource Just4Me Medicare	$1,058.25
Rate for Payer: Humana Medicare Advantage	$783.89
Rate for Payer: Molina Healthcare Benefit Exchange	$940.67

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS

Facility

$2,303.66

Service Code	CPT 43250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.47
Max. Negotiated Rate	$2,303.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

Facility

$2,303.66

Service Code	CPT 43251
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.47
Max. Negotiated Rate	$2,303.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)

Facility

$2,303.66

Service Code	CPT 43249
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.47
Max. Negotiated Rate	$2,303.66
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56

ESOPHAGOMYOTOMY ABDOMINAL

Facility

$1,530.00

Service Code	HCPCS 43330
Hospital Charge Code	76101772
Hospital Revenue Code	761
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$1,468.80
Rate for Payer: Aetna Commercial	$1,178.10
Rate for Payer: Anthem Medicaid	$526.17
Rate for Payer: Anthem POS/PPO/Traditional	$1,193.40
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$1,269.90
Rate for Payer: First Health Commercial	$1,453.50
Rate for Payer: Humana Commercial	$1,300.50
Rate for Payer: Humana KY Medicaid	$526.17
Rate for Payer: Kentucky WC Medicaid	$531.52
Rate for Payer: Medical Mutual Of Ohio HMO	$1,254.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,129.14
Rate for Payer: Molina Healthcare Benefit Exchange	$459.00
Rate for Payer: Molina Healthcare Medicaid	$536.72
Rate for Payer: Ohio Health Choice Commercial	$1,346.40
Rate for Payer: Ohio Health Group HMO	$1,147.50
Rate for Payer: Ohio Health Group PPO Differential	$306.00
Rate for Payer: Ohio Health Group PPO No Differential	$198.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$474.30
Rate for Payer: PHCS Commercial	$1,468.80
Rate for Payer: United Healthcare All Payer	$1,346.40

ESOPHAGOMYOTOMY ABDOMINAL

Facility

$1,530.00

Service Code	HCPCS 43330
Hospital Charge Code	76101772
Hospital Revenue Code	761
Min. Negotiated Rate	$198.90
Max. Negotiated Rate	$1,468.80
Rate for Payer: Aetna Commercial	$1,178.10
Rate for Payer: Anthem POS/PPO/Traditional	$1,193.40
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$1,269.90
Rate for Payer: First Health Commercial	$1,453.50
Rate for Payer: Humana Commercial	$1,300.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,254.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,129.14
Rate for Payer: Molina Healthcare Benefit Exchange	$459.00
Rate for Payer: Ohio Health Choice Commercial	$1,346.40
Rate for Payer: Ohio Health Group HMO	$1,147.50
Rate for Payer: Ohio Health Group PPO Differential	$306.00
Rate for Payer: Ohio Health Group PPO No Differential	$198.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$474.30
Rate for Payer: PHCS Commercial	$1,468.80
Rate for Payer: United Healthcare All Payer	$1,346.40

ESOPHAGOMYOTOMY ABDOMINAL

Professional

Both

$1,530.00

Service Code	HCPCS 43330
Hospital Charge Code	76101772
Hospital Revenue Code	761
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,916.20
Rate for Payer: Aetna Commercial	$1,916.20
Rate for Payer: Anthem Medicaid	$781.50
Rate for Payer: Buckeye Medicare Advantage	$1,530.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$1,786.91
Rate for Payer: Healthspan PPO	$1,615.96
Rate for Payer: Humana Medicaid	$781.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,693.49
Rate for Payer: Molina Healthcare CHIP/Medicaid	$797.13
Rate for Payer: Molina Healthcare Passport	$781.50
Rate for Payer: Multiplan PHCS	$918.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,071.00
Rate for Payer: UHCCP Medicaid	$535.50
Rate for Payer: Wellcare CHIP/Medicaid	$789.32

ESOPHAGOMYOTOMY ABDOMINAL(P

Professional

Both

$1,530.00

Service Code	HCPCS 43330
Hospital Charge Code	761P1772
Hospital Revenue Code	761
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,916.20
Rate for Payer: Aetna Commercial	$1,916.20
Rate for Payer: Anthem Medicaid	$781.50
Rate for Payer: Buckeye Medicare Advantage	$1,530.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$1,786.91
Rate for Payer: Healthspan PPO	$1,615.96
Rate for Payer: Humana Medicaid	$781.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,693.49
Rate for Payer: Molina Healthcare CHIP/Medicaid	$797.13
Rate for Payer: Molina Healthcare Passport	$781.50
Rate for Payer: Multiplan PHCS	$918.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,071.00
Rate for Payer: UHCCP Medicaid	$535.50
Rate for Payer: Wellcare CHIP/Medicaid	$789.32

ESOPHAGOSCOPY

Facility

$3,234.13

Service Code	HCPCS 43200
Hospital Charge Code	76101726
Hospital Revenue Code	761
Min. Negotiated Rate	$420.44
Max. Negotiated Rate	$3,104.76
Rate for Payer: Aetna Commercial	$2,490.28
Rate for Payer: Anthem POS/PPO/Traditional	$2,522.62
Rate for Payer: Cash Price	$1,617.07
Rate for Payer: Cigna Commercial	$2,684.33
Rate for Payer: First Health Commercial	$3,072.42
Rate for Payer: Humana Commercial	$2,749.01
Rate for Payer: Medical Mutual Of Ohio HMO	$2,651.99
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,386.79
Rate for Payer: Molina Healthcare Benefit Exchange	$970.24
Rate for Payer: Ohio Health Choice Commercial	$2,846.03
Rate for Payer: Ohio Health Group HMO	$2,425.60
Rate for Payer: Ohio Health Group PPO Differential	$646.83
Rate for Payer: Ohio Health Group PPO No Differential	$420.44
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,002.58
Rate for Payer: PHCS Commercial	$3,104.76
Rate for Payer: United Healthcare All Payer	$2,846.03

ESOPHAGOSCOPY

Facility

$3,234.13

Service Code	HCPCS 43200
Hospital Charge Code	76101726
Hospital Revenue Code	761
Min. Negotiated Rate	$420.44
Max. Negotiated Rate	$3,104.76
Rate for Payer: Aetna Commercial	$2,490.28
Rate for Payer: Anthem Medicaid	$1,112.22
Rate for Payer: Anthem Medicare Advantage/PPO	$783.89
Rate for Payer: Anthem POS/PPO/Traditional	$2,522.62
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,097.45
Rate for Payer: CareSource Just4Me Medicare	$1,058.25
Rate for Payer: Cash Price	$1,617.07
Rate for Payer: Cash Price	$1,617.07
Rate for Payer: Cigna Commercial	$2,684.33
Rate for Payer: First Health Commercial	$3,072.42
Rate for Payer: Humana Commercial	$2,749.01
Rate for Payer: Humana KY Medicaid	$1,112.22
Rate for Payer: Humana Medicare Advantage	$783.89
Rate for Payer: Kentucky WC Medicaid	$1,123.54
Rate for Payer: Medical Mutual Of Ohio HMO	$2,651.99
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,386.79
Rate for Payer: Molina Healthcare Benefit Exchange	$940.67
Rate for Payer: Molina Healthcare Medicaid	$1,134.53
Rate for Payer: Ohio Health Choice Commercial	$2,846.03
Rate for Payer: Ohio Health Group HMO	$2,425.60
Rate for Payer: Ohio Health Group PPO Differential	$646.83
Rate for Payer: Ohio Health Group PPO No Differential	$420.44
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,002.58
Rate for Payer: PHCS Commercial	$3,104.76
Rate for Payer: United Healthcare All Payer	$2,846.03

ESOPHAGOSCOPY

Professional

Both

$3,234.13

Service Code	HCPCS 43200
Hospital Charge Code	76101726
Hospital Revenue Code	761
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$3,234.13
Rate for Payer: Aetna Commercial	$155.63
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$87.50
Rate for Payer: Anthem Medicaid	$107.69
Rate for Payer: Buckeye Medicare Advantage	$3,234.13
Rate for Payer: Cash Price	$1,617.07
Rate for Payer: Cash Price	$1,617.07
Rate for Payer: Cigna Commercial	$149.16
Rate for Payer: Healthspan PPO	$255.38
Rate for Payer: Humana Medicaid	$107.69
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$135.80
Rate for Payer: Molina Healthcare CHIP/Medicaid	$109.84
Rate for Payer: Molina Healthcare Passport	$107.69
Rate for Payer: Multiplan PHCS	$1,940.48
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,263.89
Rate for Payer: UHCCP Medicaid	$91.88
Rate for Payer: Wellcare CHIP/Medicaid	$108.77

ESOPHAGOSCOPY

Professional

Both

$3,323.75

Service Code	HCPCS 43202
Hospital Charge Code	76101728
Hospital Revenue Code	761
Min. Negotiated Rate	$97.44
Max. Negotiated Rate	$3,323.75
Rate for Payer: Aetna Commercial	$173.30
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$97.44
Rate for Payer: Anthem Medicaid	$127.63
Rate for Payer: Buckeye Medicare Advantage	$3,323.75
Rate for Payer: Cash Price	$1,661.88
Rate for Payer: Cash Price	$1,661.88
Rate for Payer: Cigna Commercial	$161.26
Rate for Payer: Healthspan PPO	$334.37
Rate for Payer: Humana Medicaid	$127.63
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$150.35
Rate for Payer: Molina Healthcare CHIP/Medicaid	$130.18
Rate for Payer: Molina Healthcare Passport	$127.63
Rate for Payer: Multiplan PHCS	$1,994.25
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,326.62
Rate for Payer: UHCCP Medicaid	$102.31
Rate for Payer: Wellcare CHIP/Medicaid	$128.91

ESOPHAGOSCOPY

Facility

$3,323.75

Service Code	HCPCS 43202
Hospital Charge Code	76101728
Hospital Revenue Code	761
Min. Negotiated Rate	$432.09
Max. Negotiated Rate	$3,190.80
Rate for Payer: Aetna Commercial	$2,559.29
Rate for Payer: Anthem Medicaid	$1,143.04
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Anthem POS/PPO/Traditional	$2,592.52
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Cash Price	$1,661.88
Rate for Payer: Cash Price	$1,661.88
Rate for Payer: Cigna Commercial	$2,758.71
Rate for Payer: First Health Commercial	$3,157.56
Rate for Payer: Humana Commercial	$2,825.19
Rate for Payer: Humana KY Medicaid	$1,143.04
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Kentucky WC Medicaid	$1,154.67
Rate for Payer: Medical Mutual Of Ohio HMO	$2,725.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,452.93
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56
Rate for Payer: Molina Healthcare Medicaid	$1,165.97
Rate for Payer: Ohio Health Choice Commercial	$2,924.90
Rate for Payer: Ohio Health Group HMO	$2,492.81
Rate for Payer: Ohio Health Group PPO Differential	$664.75
Rate for Payer: Ohio Health Group PPO No Differential	$432.09
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,030.36
Rate for Payer: PHCS Commercial	$3,190.80
Rate for Payer: United Healthcare All Payer	$2,924.90

ESOPHAGOSCOPY

Facility

$3,323.75

Service Code	HCPCS 43202
Hospital Charge Code	76101728
Hospital Revenue Code	761
Min. Negotiated Rate	$432.09
Max. Negotiated Rate	$3,190.80
Rate for Payer: Aetna Commercial	$2,559.29
Rate for Payer: Anthem POS/PPO/Traditional	$2,592.52
Rate for Payer: Cash Price	$1,661.88
Rate for Payer: Cigna Commercial	$2,758.71
Rate for Payer: First Health Commercial	$3,157.56
Rate for Payer: Humana Commercial	$2,825.19
Rate for Payer: Medical Mutual Of Ohio HMO	$2,725.48
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,452.93
Rate for Payer: Molina Healthcare Benefit Exchange	$997.12
Rate for Payer: Ohio Health Choice Commercial	$2,924.90
Rate for Payer: Ohio Health Group HMO	$2,492.81
Rate for Payer: Ohio Health Group PPO Differential	$664.75
Rate for Payer: Ohio Health Group PPO No Differential	$432.09
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,030.36
Rate for Payer: PHCS Commercial	$3,190.80
Rate for Payer: United Healthcare All Payer	$2,924.90

ESOPHAGOSCOPY BALLOON <30MM

Facility

$3,955.40

Service Code	HCPCS 43220
Hospital Charge Code	76101732
Hospital Revenue Code	761
Min. Negotiated Rate	$514.20
Max. Negotiated Rate	$3,797.18
Rate for Payer: Aetna Commercial	$3,045.66
Rate for Payer: Anthem Medicaid	$1,360.26
Rate for Payer: Anthem Medicare Advantage/PPO	$1,645.47
Rate for Payer: Anthem POS/PPO/Traditional	$3,085.21
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,303.66
Rate for Payer: CareSource Just4Me Medicare	$2,221.38
Rate for Payer: Cash Price	$1,977.70
Rate for Payer: Cash Price	$1,977.70
Rate for Payer: Cigna Commercial	$3,282.98
Rate for Payer: First Health Commercial	$3,757.63
Rate for Payer: Humana Commercial	$3,362.09
Rate for Payer: Humana KY Medicaid	$1,360.26
Rate for Payer: Humana Medicare Advantage	$1,645.47
Rate for Payer: Kentucky WC Medicaid	$1,374.11
Rate for Payer: Medical Mutual Of Ohio HMO	$3,243.43
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,919.09
Rate for Payer: Molina Healthcare Benefit Exchange	$1,974.56
Rate for Payer: Molina Healthcare Medicaid	$1,387.55
Rate for Payer: Ohio Health Choice Commercial	$3,480.75
Rate for Payer: Ohio Health Group HMO	$2,966.55
Rate for Payer: Ohio Health Group PPO Differential	$791.08
Rate for Payer: Ohio Health Group PPO No Differential	$514.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,226.17
Rate for Payer: PHCS Commercial	$3,797.18
Rate for Payer: United Healthcare All Payer	$3,480.75

ESOPHAGOSCOPY BALLOON <30MM

Professional

Both

$3,955.40

Service Code	HCPCS 43220
Hospital Charge Code	76101732
Hospital Revenue Code	761
Min. Negotiated Rate	$108.36
Max. Negotiated Rate	$3,955.40
Rate for Payer: Aetna Commercial	$192.75
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$108.36
Rate for Payer: Anthem Medicaid	$140.06
Rate for Payer: Buckeye Medicare Advantage	$3,955.40
Rate for Payer: Cash Price	$1,977.70
Rate for Payer: Cash Price	$1,977.70
Rate for Payer: Cigna Commercial	$176.93
Rate for Payer: Healthspan PPO	$162.55
Rate for Payer: Humana Medicaid	$140.06
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$165.93
Rate for Payer: Molina Healthcare CHIP/Medicaid	$142.86
Rate for Payer: Molina Healthcare Passport	$140.06
Rate for Payer: Multiplan PHCS	$2,373.24
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,768.78
Rate for Payer: UHCCP Medicaid	$113.78
Rate for Payer: Wellcare CHIP/Medicaid	$141.46

ESOPHAGOSCOPY BALLOON <30MM

Facility

$3,955.40

Service Code	HCPCS 43220
Hospital Charge Code	76101732
Hospital Revenue Code	761
Min. Negotiated Rate	$514.20
Max. Negotiated Rate	$3,797.18
Rate for Payer: Aetna Commercial	$3,045.66
Rate for Payer: Anthem POS/PPO/Traditional	$3,085.21
Rate for Payer: Cash Price	$1,977.70
Rate for Payer: Cigna Commercial	$3,282.98
Rate for Payer: First Health Commercial	$3,757.63
Rate for Payer: Humana Commercial	$3,362.09
Rate for Payer: Medical Mutual Of Ohio HMO	$3,243.43
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,919.09
Rate for Payer: Molina Healthcare Benefit Exchange	$1,186.62
Rate for Payer: Ohio Health Choice Commercial	$3,480.75
Rate for Payer: Ohio Health Group HMO	$2,966.55
Rate for Payer: Ohio Health Group PPO Differential	$791.08
Rate for Payer: Ohio Health Group PPO No Differential	$514.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,226.17
Rate for Payer: PHCS Commercial	$3,797.18
Rate for Payer: United Healthcare All Payer	$3,480.75

ESOPHAGOSCOPY BALLOON <30MM(P

Professional

Both

$825.00

Service Code	HCPCS 43220
Hospital Charge Code	761P1732
Hospital Revenue Code	761
Min. Negotiated Rate	$108.36
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna Commercial	$192.75
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$108.36
Rate for Payer: Anthem Medicaid	$140.06
Rate for Payer: Buckeye Medicare Advantage	$825.00
Rate for Payer: Cash Price	$412.50
Rate for Payer: Cash Price	$412.50
Rate for Payer: Cigna Commercial	$176.93
Rate for Payer: Healthspan PPO	$162.55
Rate for Payer: Humana Medicaid	$140.06
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$165.93
Rate for Payer: Molina Healthcare CHIP/Medicaid	$142.86
Rate for Payer: Molina Healthcare Passport	$140.06
Rate for Payer: Multiplan PHCS	$495.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$577.50
Rate for Payer: UHCCP Medicaid	$113.78
Rate for Payer: Wellcare CHIP/Medicaid	$141.46

ESOPHAGOSCOPY BALLOON <30MM(T

Facility

$3,130.40

Service Code	HCPCS 43220
Hospital Charge Code	761T1732
Hospital Revenue Code	761
Min. Negotiated Rate	$406.95
Max. Negotiated Rate	$3,005.18
Rate for Payer: Aetna Commercial	$2,410.41
Rate for Payer: Anthem POS/PPO/Traditional	$2,441.71
Rate for Payer: Cash Price	$1,565.20
Rate for Payer: Cigna Commercial	$2,598.23
Rate for Payer: First Health Commercial	$2,973.88
Rate for Payer: Humana Commercial	$2,660.84
Rate for Payer: Medical Mutual Of Ohio HMO	$2,566.93
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,310.24
Rate for Payer: Molina Healthcare Benefit Exchange	$939.12
Rate for Payer: Ohio Health Choice Commercial	$2,754.75
Rate for Payer: Ohio Health Group HMO	$2,347.80
Rate for Payer: Ohio Health Group PPO Differential	$626.08
Rate for Payer: Ohio Health Group PPO No Differential	$406.95
Rate for Payer: Ohio Health Group PPO SOMC Employees	$970.42
Rate for Payer: PHCS Commercial	$3,005.18
Rate for Payer: United Healthcare All Payer	$2,754.75

Know your out-of-pocket cost for care.

All Charges