Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ESOPHAGEAL CAPSULE ENDOSCOPY

Professional

Both

$1,448.00

Service Code	HCPCS 91111
Hospital Charge Code	75000007
Hospital Revenue Code	750
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$1,020.39
Rate for Payer: Aetna Commercial	$1,020.39
Rate for Payer: Ambetter Exchange	$735.06
Rate for Payer: Anthem Medicaid	$584.25
Rate for Payer: Buckeye Individual/Medicaid	$735.06
Rate for Payer: Buckeye Medicare Advantage	$735.06
Rate for Payer: CareSource Just4Me Medicare	$882.07
Rate for Payer: Cash Price	$724.00
Rate for Payer: Cash Price	$724.00
Rate for Payer: Cigna Commercial	$942.95
Rate for Payer: Healthspan PPO	$835.02
Rate for Payer: Humana Medicaid	$584.25
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$68.82
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$735.06
Rate for Payer: Molina Healthcare Benefit Exchange	$735.06
Rate for Payer: Molina Healthcare CHIP/Medicaid	$595.93
Rate for Payer: Molina Healthcare Passport	$584.25
Rate for Payer: Multiplan PHCS	$868.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$955.58
Rate for Payer: UHCCP Medicaid	$506.80
Rate for Payer: Wellcare CHIP/Medicaid	$590.09
Rate for Payer: Wellcare Medicare Advantage	$735.06

ESOPHAGEAL FUNCTION IMPEDENCE

Facility

$1,075.00

Service Code	HCPCS 91037
Hospital Charge Code	75000004
Hospital Revenue Code	750
Min. Negotiated Rate	$287.73
Max. Negotiated Rate	$1,032.00
Rate for Payer: Aetna Commercial	$827.75
Rate for Payer: Anthem Medicaid	$369.69
Rate for Payer: Anthem Medicare Advantage/PPO	$287.73
Rate for Payer: Anthem POS/PPO/Traditional	$838.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$402.82
Rate for Payer: CareSource Just4Me Medicare	$388.44
Rate for Payer: Cash Price	$537.50
Rate for Payer: Cash Price	$537.50
Rate for Payer: Cigna Commercial	$892.25
Rate for Payer: First Health Commercial	$1,021.25
Rate for Payer: Humana Commercial	$913.75
Rate for Payer: Humana KY Medicaid	$369.69
Rate for Payer: Humana Medicare Advantage	$287.73
Rate for Payer: Kentucky WC Medicaid	$373.45
Rate for Payer: Medical Mutual Of Ohio HMO	$881.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$793.35
Rate for Payer: Molina Healthcare Benefit Exchange	$345.28
Rate for Payer: Molina Healthcare Medicaid	$377.11
Rate for Payer: Ohio Health Choice Commercial	$946.00
Rate for Payer: Ohio Health Group HMO	$806.25
Rate for Payer: Ohio Health Group PPO Differential	$860.00
Rate for Payer: Ohio Health Group PPO No Differential	$935.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$741.75
Rate for Payer: PHCS Commercial	$1,032.00
Rate for Payer: United Healthcare All Payer	$946.00

ESOPHAGEAL FUNCTION IMPEDENCE

Professional

Both

$1,075.00

Service Code	HCPCS 91037
Hospital Charge Code	75000004
Hospital Revenue Code	750
Min. Negotiated Rate	$67.88
Max. Negotiated Rate	$645.00
Rate for Payer: Aetna Commercial	$237.42
Rate for Payer: Ambetter Exchange	$148.89
Rate for Payer: Anthem Medicaid	$106.65
Rate for Payer: Buckeye Individual/Medicaid	$148.89
Rate for Payer: Buckeye Medicare Advantage	$148.89
Rate for Payer: CareSource Just4Me Medicare	$178.67
Rate for Payer: Cash Price	$537.50
Rate for Payer: Cash Price	$537.50
Rate for Payer: Cigna Commercial	$196.36
Rate for Payer: Healthspan PPO	$194.29
Rate for Payer: Humana Medicaid	$106.65
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$67.88
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$148.89
Rate for Payer: Molina Healthcare Benefit Exchange	$148.89
Rate for Payer: Molina Healthcare CHIP/Medicaid	$108.78
Rate for Payer: Molina Healthcare Passport	$106.65
Rate for Payer: Multiplan PHCS	$645.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$193.56
Rate for Payer: UHCCP Medicaid	$376.25
Rate for Payer: Wellcare CHIP/Medicaid	$107.72
Rate for Payer: Wellcare Medicare Advantage	$148.89

ESOPHAGEAL FUNCTION IMPEDENCE

Facility

$1,075.00

Service Code	HCPCS 91037
Hospital Charge Code	75000004
Hospital Revenue Code	750
Min. Negotiated Rate	$322.50
Max. Negotiated Rate	$1,032.00
Rate for Payer: Aetna Commercial	$827.75
Rate for Payer: Anthem POS/PPO/Traditional	$838.50
Rate for Payer: Cash Price	$537.50
Rate for Payer: Cigna Commercial	$892.25
Rate for Payer: First Health Commercial	$1,021.25
Rate for Payer: Humana Commercial	$913.75
Rate for Payer: Medical Mutual Of Ohio HMO	$881.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$793.35
Rate for Payer: Molina Healthcare Benefit Exchange	$322.50
Rate for Payer: Ohio Health Choice Commercial	$946.00
Rate for Payer: Ohio Health Group HMO	$806.25
Rate for Payer: Ohio Health Group PPO Differential	$860.00
Rate for Payer: Ohio Health Group PPO No Differential	$935.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$741.75
Rate for Payer: PHCS Commercial	$1,032.00
Rate for Payer: United Healthcare All Payer	$946.00

ESOPHAGEAL FUNCTION IMPEDENC(P

Professional

Both

$260.00

Service Code	HCPCS 91037
Hospital Charge Code	750P0004
Hospital Revenue Code	750
Min. Negotiated Rate	$67.88
Max. Negotiated Rate	$237.42
Rate for Payer: Aetna Commercial	$237.42
Rate for Payer: Ambetter Exchange	$148.89
Rate for Payer: Anthem Medicaid	$106.65
Rate for Payer: Buckeye Individual/Medicaid	$148.89
Rate for Payer: Buckeye Medicare Advantage	$148.89
Rate for Payer: CareSource Just4Me Medicare	$178.67
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cigna Commercial	$196.36
Rate for Payer: Healthspan PPO	$194.29
Rate for Payer: Humana Medicaid	$106.65
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$67.88
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$148.89
Rate for Payer: Molina Healthcare Benefit Exchange	$148.89
Rate for Payer: Molina Healthcare CHIP/Medicaid	$108.78
Rate for Payer: Molina Healthcare Passport	$106.65
Rate for Payer: Multiplan PHCS	$156.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$193.56
Rate for Payer: UHCCP Medicaid	$91.00
Rate for Payer: Wellcare CHIP/Medicaid	$107.72
Rate for Payer: Wellcare Medicare Advantage	$148.89

ESOPHAGEAL FUNCTION IMPEDENC(T

Facility

$815.00

Service Code	HCPCS 91037
Hospital Charge Code	750T0004
Hospital Revenue Code	750
Min. Negotiated Rate	$280.28
Max. Negotiated Rate	$782.40
Rate for Payer: Aetna Commercial	$627.55
Rate for Payer: Anthem Medicaid	$280.28
Rate for Payer: Anthem Medicare Advantage/PPO	$287.73
Rate for Payer: Anthem POS/PPO/Traditional	$635.70
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$402.82
Rate for Payer: CareSource Just4Me Medicare	$388.44
Rate for Payer: Cash Price	$407.50
Rate for Payer: Cash Price	$407.50
Rate for Payer: Cigna Commercial	$676.45
Rate for Payer: First Health Commercial	$774.25
Rate for Payer: Humana Commercial	$692.75
Rate for Payer: Humana KY Medicaid	$280.28
Rate for Payer: Humana Medicare Advantage	$287.73
Rate for Payer: Kentucky WC Medicaid	$283.13
Rate for Payer: Medical Mutual Of Ohio HMO	$668.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$601.47
Rate for Payer: Molina Healthcare Benefit Exchange	$345.28
Rate for Payer: Molina Healthcare Medicaid	$285.90
Rate for Payer: Ohio Health Choice Commercial	$717.20
Rate for Payer: Ohio Health Group HMO	$611.25
Rate for Payer: Ohio Health Group PPO Differential	$652.00
Rate for Payer: Ohio Health Group PPO No Differential	$709.05
Rate for Payer: Ohio Health Group PPO SOMC Employees	$562.35
Rate for Payer: PHCS Commercial	$782.40
Rate for Payer: United Healthcare All Payer	$717.20

ESOPHAGEAL FUNCTION IMPEDENC(T

Facility

$815.00

Service Code	HCPCS 91037
Hospital Charge Code	750T0004
Hospital Revenue Code	750
Min. Negotiated Rate	$244.50
Max. Negotiated Rate	$782.40
Rate for Payer: Aetna Commercial	$627.55
Rate for Payer: Anthem POS/PPO/Traditional	$635.70
Rate for Payer: Cash Price	$407.50
Rate for Payer: Cigna Commercial	$676.45
Rate for Payer: First Health Commercial	$774.25
Rate for Payer: Humana Commercial	$692.75
Rate for Payer: Medical Mutual Of Ohio HMO	$668.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$601.47
Rate for Payer: Molina Healthcare Benefit Exchange	$244.50
Rate for Payer: Ohio Health Choice Commercial	$717.20
Rate for Payer: Ohio Health Group HMO	$611.25
Rate for Payer: Ohio Health Group PPO Differential	$652.00
Rate for Payer: Ohio Health Group PPO No Differential	$709.05
Rate for Payer: Ohio Health Group PPO SOMC Employees	$562.35
Rate for Payer: PHCS Commercial	$782.40
Rate for Payer: United Healthcare All Payer	$717.20

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$1,212.81

Service Code	CPT 43235
Hospital Revenue Code	360
Min. Negotiated Rate	$866.29
Max. Negotiated Rate	$1,212.81
Rate for Payer: Anthem Medicare Advantage/PPO	$866.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,212.81
Rate for Payer: CareSource Just4Me Medicare	$1,169.49
Rate for Payer: Humana Medicare Advantage	$866.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1,039.55

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)

Facility

$2,453.89

Service Code	CPT 43270
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES

Facility

$2,453.89

Service Code	CPT 43244
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$1,212.81

Service Code	CPT 43239
Hospital Revenue Code	360
Min. Negotiated Rate	$866.29
Max. Negotiated Rate	$1,212.81
Rate for Payer: Anthem Medicare Advantage/PPO	$866.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,212.81
Rate for Payer: CareSource Just4Me Medicare	$1,169.49
Rate for Payer: Humana Medicare Advantage	$866.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1,039.55

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD

Facility

$2,453.89

Service Code	CPT 43255
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

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

Facility

$2,453.89

Service Code	CPT 43245
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

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

Facility

$2,453.89

Service Code	CPT 43246
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

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

Facility

$1,212.81

Service Code	CPT 43236
Hospital Revenue Code	360
Min. Negotiated Rate	$866.29
Max. Negotiated Rate	$1,212.81
Rate for Payer: Anthem Medicare Advantage/PPO	$866.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,212.81
Rate for Payer: CareSource Just4Me Medicare	$1,169.49
Rate for Payer: Humana Medicare Advantage	$866.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1,039.55

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

Facility

$13,467.66

Service Code	CPT 43210
Hospital Revenue Code	360
Min. Negotiated Rate	$9,619.76
Max. Negotiated Rate	$13,467.66
Rate for Payer: Anthem Medicare Advantage/PPO	$9,619.76
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,467.66
Rate for Payer: CareSource Just4Me Medicare	$12,986.68
Rate for Payer: Humana Medicare Advantage	$9,619.76
Rate for Payer: Molina Healthcare Benefit Exchange	$11,543.71

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

Facility

$1,212.81

Service Code	CPT 43248
Hospital Revenue Code	360
Min. Negotiated Rate	$866.29
Max. Negotiated Rate	$1,212.81
Rate for Payer: Anthem Medicare Advantage/PPO	$866.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,212.81
Rate for Payer: CareSource Just4Me Medicare	$1,169.49
Rate for Payer: Humana Medicare Advantage	$866.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1,039.55

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

Facility

$7,700.39

Service Code	CPT 43266
Hospital Revenue Code	360
Min. Negotiated Rate	$5,500.28
Max. Negotiated Rate	$7,700.39
Rate for Payer: Anthem Medicare Advantage/PPO	$5,500.28
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,700.39
Rate for Payer: CareSource Just4Me Medicare	$7,425.38
Rate for Payer: Humana Medicare Advantage	$5,500.28
Rate for Payer: Molina Healthcare Benefit Exchange	$6,600.34

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

Facility

$1,212.81

Service Code	CPT 43247
Hospital Revenue Code	360
Min. Negotiated Rate	$866.29
Max. Negotiated Rate	$1,212.81
Rate for Payer: Anthem Medicare Advantage/PPO	$866.29
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$1,212.81
Rate for Payer: CareSource Just4Me Medicare	$1,169.49
Rate for Payer: Humana Medicare Advantage	$866.29
Rate for Payer: Molina Healthcare Benefit Exchange	$1,039.55

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

Facility

$2,453.89

Service Code	CPT 43250
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

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

Facility

$2,453.89

Service Code	CPT 43251
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

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

Facility

$2,453.89

Service Code	CPT 43249
Hospital Revenue Code	360
Min. Negotiated Rate	$1,752.78
Max. Negotiated Rate	$2,453.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,752.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,453.89
Rate for Payer: CareSource Just4Me Medicare	$2,366.25
Rate for Payer: Humana Medicare Advantage	$1,752.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,103.34

ESOPHAGOMYOTOMY ABDOMINAL

Facility

$1,530.00

Service Code	HCPCS 43330
Hospital Charge Code	76101772
Hospital Revenue Code	761
Min. Negotiated Rate	$459.00
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	$1,224.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,331.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,055.70
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	$459.00
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	$1,224.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,331.10
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,055.70
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: Ambetter Exchange	$1,274.61
Rate for Payer: Anthem Medicaid	$781.50
Rate for Payer: Buckeye Individual/Medicaid	$1,274.61
Rate for Payer: Buckeye Medicare Advantage	$1,274.61
Rate for Payer: CareSource Just4Me Medicare	$1,529.53
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: Medical Mutual Of Ohio Medicare Advantage	$1,274.61
Rate for Payer: Molina Healthcare Benefit Exchange	$1,274.61
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	$1,656.99
Rate for Payer: UHCCP Medicaid	$535.50
Rate for Payer: Wellcare CHIP/Medicaid	$789.32
Rate for Payer: Wellcare Medicare Advantage	$1,274.61

Know your out-of-pocket cost for care.

All Charges