Pomerene Hospital
Pomerene Hospital in Millersburg, OH publishes cash prices for 48 common procedures listed here, from its own machine-readable price file updated —. Click a procedure to compare it with other hospitals nearby.
981 Wooster Road, Millersburg, OH, 44654 Collected Sep 21, 2026 Source price file
Scans and imaging
| Procedure | Cash price | List price | Off list |
|---|---|---|---|
| CT scan of abdomen and pelvis, with contrast dye CPT 74177 CT ABDOMEN/PELVIS W | $1,986.40 | $2,483.00 | 20% |
| CT scan of abdomen and pelvis, with contrast dye inpatient CPT 74177 CT ABDOMEN/PELVIS W | $1,986.40 | $2,483.00 | 20% |
| CT scan of the head or brain, no contrast dye CPT 70450 CT BRAIN W/O CONTRAST | $900.00 | $1,125.00 | 20% |
| CT scan of the head or brain, no contrast dye inpatient CPT 70450 CT BRAIN W/O CONTRAST | $900.00 | $1,125.00 | 20% |
| CT scan of the pelvis, with contrast dye CPT 72193 CT PELVIS W/CONTRAST | $1,225.60 | $1,532.00 | 20% |
| CT scan of the pelvis, with contrast dye inpatient CPT 72193 CT PELVIS W/CONTRAST | $1,225.60 | $1,532.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC SPECIAL | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 MAMMOGRAM HOFFNUNG BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC BCCP | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 3D MAMM HOFFNUNG BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 3D MAMM BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 3D MAMM BILAT DIAG SPECIAL | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts both sides CPT 77066 3D MAMM BILAT DIAG BCCP | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC SPECIAL | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC BCCP | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 3D MAMM BILAT DIAG BCCP | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 3D MAMM BILAT DIAG SPECIAL | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 3D MAMM BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 3D MAMM HOFFNUNG BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 MAMM DIGITAL BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, both breasts inpatient both sides CPT 77066 MAMMOGRAM HOFFNUNG BILAT DIAGNOSTIC | $208.80 | $261.00 | 20% |
| Diagnostic mammogram, one breast one side CPT 77065 MAMM DIGITAL UNILAT DIAG ST JOHNS | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast one side CPT 77065 MAMM DIGITAL UNILAT DIAGNOSTIC RT | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast one side CPT 77065 3D MAMM UNILAT LT DIAGNOSTIC | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast one side CPT 77065 3D MAMM UNILAT RT DIAGNOSTIC | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast one side CPT 77065 MAMM DIGITAL DIAGNOSTIC UNILAT LT | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast inpatient one side CPT 77065 3D MAMM UNILAT RT DIAGNOSTIC | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast inpatient one side CPT 77065 3D MAMM UNILAT LT DIAGNOSTIC | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast inpatient one side CPT 77065 MAMM DIGITAL UNILAT DIAGNOSTIC RT | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast inpatient one side CPT 77065 MAMM DIGITAL UNILAT DIAG ST JOHNS | $184.00 | $230.00 | 20% |
| Diagnostic mammogram, one breast inpatient one side CPT 77065 MAMM DIGITAL DIAGNOSTIC UNILAT LT | $184.00 | $230.00 | 20% |
| MRI of the brain, no contrast dye CPT 70551 MR MRI BRAIN W/O CONTRAST | $1,635.20 | $2,044.00 | 20% |
| MRI of the brain, no contrast dye inpatient CPT 70551 MR MRI BRAIN W/O CONTRAST | $1,635.20 | $2,044.00 | 20% |
| MRI of the brain, with and without contrast dye CPT 70553 MR MRI BRAIN W/WO CONTRAST | $2,475.20 | $3,094.00 | 20% |
| MRI of the brain, with and without contrast dye inpatient CPT 70553 MR MRI BRAIN W/WO CONTRAST | $2,475.20 | $3,094.00 | 20% |
| MRI of the lower back, no contrast dye CPT 72148 MR LUMBAR SP WO CONTRAST | $1,840.00 | $2,300.00 | 20% |
| MRI of the lower back, no contrast dye inpatient CPT 72148 MR LUMBAR SP WO CONTRAST | $1,840.00 | $2,300.00 | 20% |
| Pregnancy ultrasound after 14 weeks, one baby CPT 76805 US OB INITIAL >or= 14 WEEKS; 1st GESTAT | $352.80 | $441.00 | 20% |
| Pregnancy ultrasound after 14 weeks, one baby inpatient CPT 76805 US OB INITIAL >or= 14 WEEKS; 1st GESTAT | $352.80 | $441.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 3D MAMM HOFFNUNG BILAT SCREENING | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 MAMMOGRAM HOFFNUNG BILAT SCREENING | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 MAMM DIGITAL BILAT SCREENING BCCP | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 MAMM DIGITAL BILAT SCREEN SPECIAL | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 MAMM DIGITAL BILAT SCREEN | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 3D MAMM BILAT SCREEN SPECIAL | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 3D MAMM BILAT SCREEN BCCP | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts both sides CPT 77067 3D MAMM BILAT SCREEN | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 3D MAMM BILAT SCREEN | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 MAMM DIGITAL BILAT SCREEN | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 3D MAMM HOFFNUNG BILAT SCREENING | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 3D MAMM BILAT SCREEN SPECIAL | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 3D MAMM BILAT SCREEN BCCP | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 MAMMOGRAM HOFFNUNG BILAT SCREENING | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 MAMM DIGITAL BILAT SCREENING BCCP | $223.20 | $279.00 | 20% |
| Screening mammogram, both breasts inpatient both sides CPT 77067 MAMM DIGITAL BILAT SCREEN SPECIAL | $223.20 | $279.00 | 20% |
| Sleep study in a lab (polysomnography) CPT 95810 SLEEP LAB PSG DIAGNOSTIC | $3,869.60 | $4,837.00 | 20% |
| Sleep study in a lab (polysomnography) inpatient CPT 95810 SLEEP LAB PSG DIAGNOSTIC | $3,869.60 | $4,837.00 | 20% |
| Transvaginal pelvic ultrasound CPT 76830 US PELVIC ENDO VAGINAL | $468.00 | $585.00 | 20% |
| Transvaginal pelvic ultrasound inpatient CPT 76830 US PELVIC ENDO VAGINAL | $468.00 | $585.00 | 20% |
| Ultrasound of the abdomen, complete CPT 76700 US ABD COMPLETE | $640.00 | $800.00 | 20% |
| Ultrasound of the abdomen, complete inpatient CPT 76700 US ABD COMPLETE | $640.00 | $800.00 | 20% |
| X-ray of the lower back, 4 or more views CPT 72110 LUMBO SACRAL COMPLETE MIN 4 VIEWS | $420.80 | $526.00 | 20% |
| X-ray of the lower back, 4 or more views inpatient CPT 72110 LUMBO SACRAL COMPLETE MIN 4 VIEWS | $420.80 | $526.00 | 20% |
Lab tests
| Procedure | Cash price | List price | Off list |
|---|---|---|---|
| Basic metabolic panel (blood test) CPT 80048 BMP with eGFR | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) CPT 80048 BMP with eGFR Q4H | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) CPT 80048 BMP with MG DAILY | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) CPT 80048 BMP with eGFR DAILY | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) inpatient CPT 80048 BMP with eGFR | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) inpatient CPT 80048 BMP with MG DAILY | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) inpatient CPT 80048 BMP with eGFR DAILY | $56.00 | $70.00 | 20% |
| Basic metabolic panel (blood test) inpatient CPT 80048 BMP with eGFR Q4H | $56.00 | $70.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test CPT 80061 LIPID PROFILE | $88.80 | $111.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test CPT 80061 NMR LIPOPROFILE [CCL] | $88.80 | $111.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test CPT 80061 LIPID PANEL, BASIC [CCL] | $88.80 | $111.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 LIPID PANEL, BASIC [CCL] | $88.80 | $111.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 LIPID PROFILE | $88.80 | $111.00 | 20% |
| Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 NMR LIPOPROFILE [CCL] | $88.80 | $111.00 | 20% |
| Complete blood count (CBC) with differential CPT 85025 CBC DAILY | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential CPT 85025 CBC + DIFF DAILY | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential CPT 85025 CBC W/ MANUAL DIFF | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential CPT 85025 CBC + DIFF | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential inpatient CPT 85025 CBC + DIFF | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential inpatient CPT 85025 CBC + DIFF DAILY | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential inpatient CPT 85025 CBC DAILY | $47.20 | $59.00 | 20% |
| Complete blood count (CBC) with differential inpatient CPT 85025 CBC W/ MANUAL DIFF | $47.20 | $59.00 | 20% |
| Complete blood count (CBC), no differential CPT 85027 CBC (NO DIFF) | $37.60 | $47.00 | 20% |
| Complete blood count (CBC), no differential inpatient CPT 85027 CBC (NO DIFF) | $37.60 | $47.00 | 20% |
| Comprehensive metabolic panel (blood test) CPT 80053 CMP with eGFR | $112.80 | $141.00 | 20% |
| Comprehensive metabolic panel (blood test) CPT 80053 CMP with eGFR - DAILY | $112.80 | $141.00 | 20% |
| Comprehensive metabolic panel (blood test) CPT 80053 CMP with eGFR [CCL] | $112.80 | $141.00 | 20% |
| Comprehensive metabolic panel (blood test) inpatient CPT 80053 CMP with eGFR [CCL] | $112.80 | $141.00 | 20% |
| Comprehensive metabolic panel (blood test) inpatient CPT 80053 CMP with eGFR - DAILY | $112.80 | $141.00 | 20% |
| Comprehensive metabolic panel (blood test) inpatient CPT 80053 CMP with eGFR | $112.80 | $141.00 | 20% |
| Kidney function blood test panel CPT 80069 RENAL FUNCTION PANEL | $61.60 | $77.00 | 20% |
| Kidney function blood test panel CPT 80069 RENAL FUNCTION PANEL [CCL] | $63.20 | $79.00 | 20% |
| Kidney function blood test panel CPT 80069 RENAL FUNCTION PANEL WITH eGFR | $63.20 | $79.00 | 20% |
| Kidney function blood test panel inpatient CPT 80069 RENAL FUNCTION PANEL | $61.60 | $77.00 | 20% |
| Kidney function blood test panel inpatient CPT 80069 RENAL FUNCTION PANEL WITH eGFR | $63.20 | $79.00 | 20% |
| Kidney function blood test panel inpatient CPT 80069 RENAL FUNCTION PANEL [CCL] | $63.20 | $79.00 | 20% |
| Liver function blood test panel CPT 80076 LIVER FUNCTION/COMMUNITY OUTREACH ONLY | $36.00 | $45.00 | 20% |
| Liver function blood test panel CPT 80076 HEPATIC FUNCTION PANEL | $70.40 | $88.00 | 20% |
| Liver function blood test panel inpatient CPT 80076 LIVER FUNCTION/COMMUNITY OUTREACH ONLY | $36.00 | $45.00 | 20% |
| Liver function blood test panel inpatient CPT 80076 HEPATIC FUNCTION PANEL | $70.40 | $88.00 | 20% |
| Obstetric blood test panel CPT 80055 OB PANEL | $88.00 | $110.00 | 20% |
| Obstetric blood test panel inpatient CPT 80055 OB PANEL | $88.00 | $110.00 | 20% |
| PSA (prostate-specific antigen) blood test, free CPT 84154 PSA, FREE [CCL] | $35.20 | $44.00 | 20% |
| PSA (prostate-specific antigen) blood test, free inpatient CPT 84154 PSA, FREE [CCL] | $35.20 | $44.00 | 20% |
| PSA (prostate-specific antigen) blood test, total CPT 84153 PSA CANCER SCREENING (G0103) | $51.20 | $64.00 | 20% |
| PSA (prostate-specific antigen) blood test, total CPT 84153 PSA TOTAL 84153 (Cancer/Elevated) | $61.60 | $77.00 | 20% |
| PSA (prostate-specific antigen) blood test, total CPT 84153 PSA [CCL] | $61.60 | $77.00 | 20% |
| PSA (prostate-specific antigen) blood test, total CPT 84153 PSA SCREENING [CCL] | $61.60 | $77.00 | 20% |
| PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 PSA CANCER SCREENING (G0103) | $51.20 | $64.00 | 20% |
| PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 PSA TOTAL 84153 (Cancer/Elevated) | $61.60 | $77.00 | 20% |
| PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 PSA [CCL] | $61.60 | $77.00 | 20% |
| PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 PSA SCREENING [CCL] | $61.60 | $77.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 APTT - DAILY | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 APTT | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 APTT [CCL] | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 APTT-HEPARIN | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 PROLONGED aPTT ASYMPOTMATIC EVA | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test CPT 85730 PTT-LA | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 APTT [CCL] | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 PTT-LA | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 APTT - DAILY | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 APTT | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 PROLONGED aPTT ASYMPOTMATIC EVA | $39.20 | $49.00 | 20% |
| Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 APTT-HEPARIN | $39.20 | $49.00 | 20% |
| Prothrombin time (PT/INR) clotting test CPT 85610 PT/INR DAILY PATIENT ON COUMADIN | $24.00 | $30.00 | 20% |
| Prothrombin time (PT/INR) clotting test CPT 85610 PROTHROMBIN TIME AND INR | $24.00 | $30.00 | 20% |
| Prothrombin time (PT/INR) clotting test CPT 85610 PROTIME [CCL] | $24.00 | $30.00 | 20% |
| Prothrombin time (PT/INR) clotting test inpatient CPT 85610 PROTIME [CCL] | $24.00 | $30.00 | 20% |
| Prothrombin time (PT/INR) clotting test inpatient CPT 85610 PT/INR DAILY PATIENT ON COUMADIN | $24.00 | $30.00 | 20% |
| Prothrombin time (PT/INR) clotting test inpatient CPT 85610 PROTHROMBIN TIME AND INR | $24.00 | $30.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 THYROID CASCADING REFLEX | $77.60 | $97.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH [CCL] | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH [AULTMAN] | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH 3RD GENERATION | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH W/ REFLEX TO FREE T4 | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 THYROID CASCADING REFLEX | $77.60 | $97.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH 3RD GENERATION | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH [CCL] | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH W/ REFLEX TO FREE T4 | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH [AULTMAN] | $80.80 | $101.00 | 20% |
| Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH | $80.80 | $101.00 | 20% |
| Urinalysis with microscope exam, automated CPT 81001 URINALYSIS WITH MICROSCOPY | $32.00 | $40.00 | 20% |
| Urinalysis with microscope exam, automated CPT 81001 URINALYSIS | $32.00 | $40.00 | 20% |
| Urinalysis with microscope exam, automated inpatient CPT 81001 URINALYSIS | $32.00 | $40.00 | 20% |
| Urinalysis with microscope exam, automated inpatient CPT 81001 URINALYSIS WITH MICROSCOPY | $32.00 | $40.00 | 20% |
| Urinalysis without microscope exam, automated CPT 81003 URINALYSIS WITHOUT MICROSCOPY | $20.00 | $25.00 | 20% |
| Urinalysis without microscope exam, automated inpatient CPT 81003 URINALYSIS WITHOUT MICROSCOPY | $20.00 | $25.00 | 20% |
| Urinalysis without microscope exam, manual CPT 81002 KETONE URINE | $18.40 | $23.00 | 20% |
| Urinalysis without microscope exam, manual CPT 81002 SPEC GRAVITY | $18.40 | $23.00 | 20% |
| Urinalysis without microscope exam, manual inpatient CPT 81002 SPEC GRAVITY | $18.40 | $23.00 | 20% |
| Urinalysis without microscope exam, manual inpatient CPT 81002 KETONE URINE | $18.40 | $23.00 | 20% |
Surgery and procedures
| Procedure | Cash price | List price | Off list |
|---|---|---|---|
| Colonoscopy with polyp removal CPT 45385 COLSC FLX W-RMVL OF TUMOR POLYP LESION SNARE TQ | $3,055.64 | $3,819.55 | 20% |
| Colonoscopy with tissue sample CPT 45380 COLONOSCOPY W-BIOPSY SINGLE-MULTIPLE | $3,035.35 | $3,794.19 | 20% |
| Colonoscopy, diagnostic CPT 45378 COLONOSCOPY FLX DX W-COLLJ SPEC WHEN PFRMD | $2,649.03 | $3,311.29 | 20% |
| Gallbladder removal, laparoscopic CPT 47562 LAPAROSCOPY SURG CHOLECYSTECTOMY | $11,266.21 | $14,082.76 | 20% |
| Inguinal (groin) hernia repair, age 5 or older CPT 49505 RPR 1ST INGUN HRNA AGE 5 YRS-GREATER THAN REDUCIBLE | $7,971.70 | $9,964.63 | 20% |
| Knee arthroscopy with meniscus trim CPT 29881 ARTHRS KNE SURG W-MENISCECTOMY MED-LAT W-SHVG | $7,370.46 | $9,213.07 | 20% |
| Lower-back epidural injection, with imaging guidance CPT 62323 INJECT,SINGLE,LUMBAR/SACRAL W/ IMAGING | $971.20 | $1,214.00 | 20% |
| Lower-back epidural injection, with imaging guidance CPT 62323 NJX DX-THER SBST INTRLMNR LMBR-SAC W-IMG GDN | $1,967.39 | $2,459.24 | 20% |
| Lower-back epidural injection, with imaging guidance inpatient CPT 62323 INJECT,SINGLE,LUMBAR/SACRAL W/ IMAGING | $971.20 | $1,214.00 | 20% |
| Lower-back nerve root steroid injection, with imaging guidance CPT 64483 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC | $1,080.00 | $1,350.00 | 20% |
| Lower-back nerve root steroid injection, with imaging guidance CPT 64483 NJX AAAND-STRD TFRML EPI LUMBAR-SACRAL 1 LEVEL | $1,958.86 | $2,448.57 | 20% |
| Lower-back nerve root steroid injection, with imaging guidance inpatient CPT 64483 NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC | $1,080.00 | $1,350.00 | 20% |
| Removal of a breast lump, open surgery CPT 19120 EXC CYST-ABERRANT BREAST TISSUE OPEN 1-GREATER THAN LESION | $3,904.80 | $4,881.00 | 20% |
| Shoulder arthroscopy: shaving of the shoulder bone (add-on to another shoulder surgery) CPT 29826 SURGICAL ARTHROSCOPY SHO W-CORACOACRM LIGM RLS | $19,372.03 | $24,215.04 | 20% |
| Tonsil and adenoid removal, child under 12 CPT 42820 TONSILLECTOMY AND ADENOIDECTOMY LESS THAN AGE 12 | $4,929.89 | $6,162.36 | 20% |
| Total hip replacement CPT 27130 ARTHRP ACETBLR-PROX FEM PROSTC AGRFT-ALGRFT | $30,323.90 | $37,904.87 | 20% |
| Total knee replacement CPT 27447 ARTHRP KNE CONDYLEANDPLATU MEDIALANDLAT COMPARTMENTS | $25,577.56 | $31,971.95 | 20% |
| Upper endoscopy (EGD) with biopsy CPT 43239 EGD TRANSORAL BIOPSY SINGLE-MULTIPLE | $3,120.37 | $3,900.46 | 20% |
| Upper endoscopy (EGD), diagnostic CPT 43235 ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC | $3,082.76 | $3,853.45 | 20% |
Doctor visits and therapy
| Procedure | Cash price | List price | Off list |
|---|---|---|---|
| New patient office visit, about 30 minutes CPT 99203 NEW PATIENT LEVEL 3 DR ZAHKA | $82.40 | $103.00 | 20% |
| New patient office visit, about 30 minutes CPT 99203 PM OFFICE VISIT NEW - LEVEL 3 | $207.20 | $259.00 | 20% |
| New patient office visit, about 30 minutes CPT 99203 CK/PK PM OFFICE VISIT NEW - LEVEL 3 | $339.20 | $424.00 | 20% |
| New patient office visit, about 30 minutes inpatient CPT 99203 NEW PATIENT LEVEL 3 DR ZAHKA | $82.40 | $103.00 | 20% |
| New patient office visit, about 30 minutes inpatient CPT 99203 PM OFFICE VISIT NEW - LEVEL 3 | $207.20 | $259.00 | 20% |
| New patient office visit, about 30 minutes inpatient CPT 99203 CK/PK PM OFFICE VISIT NEW - LEVEL 3 | $339.20 | $424.00 | 20% |
| New patient office visit, about 45 minutes CPT 99204 NEW PATIENT LEVEL 4 DR ZAHKA | $133.60 | $167.00 | 20% |
| New patient office visit, about 45 minutes CPT 99204 PM OFFICE VISIT NEW - LEVEL 4 | $324.80 | $406.00 | 20% |
| New patient office visit, about 45 minutes CPT 99204 CF/PK PM OFFICE VISIT NEW - LEVEL 4 | $500.80 | $626.00 | 20% |
| New patient office visit, about 45 minutes inpatient CPT 99204 NEW PATIENT LEVEL 4 DR ZAHKA | $133.60 | $167.00 | 20% |
| New patient office visit, about 45 minutes inpatient CPT 99204 PM OFFICE VISIT NEW - LEVEL 4 | $324.80 | $406.00 | 20% |
| New patient office visit, about 45 minutes inpatient CPT 99204 CF/PK PM OFFICE VISIT NEW - LEVEL 4 | $500.80 | $626.00 | 20% |
| New patient office visit, about 60 minutes CPT 99205 NEW PATIENT LEVEL V DR ZAHKA | $172.80 | $216.00 | 20% |
| New patient office visit, about 60 minutes CPT 99205 PM OFFICE VISIT NEW - LEVEL 5 | $431.20 | $539.00 | 20% |
| New patient office visit, about 60 minutes CPT 99205 CF/PK PM OFFICE VISIT NEW - LEVEL 5 | $607.20 | $759.00 | 20% |
| New patient office visit, about 60 minutes inpatient CPT 99205 NEW PATIENT LEVEL V DR ZAHKA | $172.80 | $216.00 | 20% |
| New patient office visit, about 60 minutes inpatient CPT 99205 PM OFFICE VISIT NEW - LEVEL 5 | $431.20 | $539.00 | 20% |
| New patient office visit, about 60 minutes inpatient CPT 99205 CF/PK PM OFFICE VISIT NEW - LEVEL 5 | $607.20 | $759.00 | 20% |
Source file: https://irp.cdn-website.com/94898d03/files/uploaded/311518658_pomerene-hospital_standardcharges.csv