Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER

Facility

$2,465.88

Service Code	CPT 52287
Hospital Revenue Code	360
Min. Negotiated Rate	$1,761.34
Max. Negotiated Rate	$2,465.88
Rate for Payer: Anthem Medicare Advantage/PPO	$1,761.34
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,465.88
Rate for Payer: CareSource Just4Me Medicare	$2,377.81
Rate for Payer: Humana Medicare Advantage	$1,761.34
Rate for Payer: Molina Healthcare Benefit Exchange	$2,113.61

CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$4,220.54

Service Code	CPT 52332
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

CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS

Facility

$11,152.93

Service Code	CPT C9740
Hospital Revenue Code	360
Min. Negotiated Rate	$7,966.38
Max. Negotiated Rate	$11,152.93
Rate for Payer: Anthem Medicare Advantage/PPO	$7,966.38
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,152.93
Rate for Payer: CareSource Just4Me Medicare	$10,754.61
Rate for Payer: Humana Medicare Advantage	$7,966.38
Rate for Payer: Molina Healthcare Benefit Exchange	$9,559.66

CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS

Facility

$4,220.54

Service Code	CPT 52001
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

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE

Facility

$2,465.88

Service Code	CPT 52310
Hospital Revenue Code	360
Min. Negotiated Rate	$1,761.34
Max. Negotiated Rate	$2,465.88
Rate for Payer: Anthem Medicare Advantage/PPO	$1,761.34
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,465.88
Rate for Payer: CareSource Just4Me Medicare	$2,377.81
Rate for Payer: Humana Medicare Advantage	$1,761.34
Rate for Payer: Molina Healthcare Benefit Exchange	$2,113.61

CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;

Facility

$2,465.88

Service Code	CPT 52005
Hospital Revenue Code	360
Min. Negotiated Rate	$1,761.34
Max. Negotiated Rate	$2,465.88
Rate for Payer: Anthem Medicare Advantage/PPO	$1,761.34
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,465.88
Rate for Payer: CareSource Just4Me Medicare	$2,377.81
Rate for Payer: Humana Medicare Advantage	$1,761.34
Rate for Payer: Molina Healthcare Benefit Exchange	$2,113.61

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$4,220.54

Service Code	CPT 52351
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

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION

Facility

$6,264.36

Service Code	CPT 52354
Hospital Revenue Code	360
Min. Negotiated Rate	$4,474.54
Max. Negotiated Rate	$6,264.36
Rate for Payer: Anthem Medicare Advantage/PPO	$4,474.54
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,264.36
Rate for Payer: CareSource Just4Me Medicare	$6,040.63
Rate for Payer: Humana Medicare Advantage	$4,474.54
Rate for Payer: Molina Healthcare Benefit Exchange	$5,369.45

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$6,264.36

Service Code	CPT 52356
Hospital Revenue Code	360
Min. Negotiated Rate	$4,474.54
Max. Negotiated Rate	$6,264.36
Rate for Payer: Anthem Medicare Advantage/PPO	$4,474.54
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,264.36
Rate for Payer: CareSource Just4Me Medicare	$6,040.63
Rate for Payer: Humana Medicare Advantage	$4,474.54
Rate for Payer: Molina Healthcare Benefit Exchange	$5,369.45

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$6,264.36

Service Code	CPT 52353
Hospital Revenue Code	360
Min. Negotiated Rate	$4,474.54
Max. Negotiated Rate	$6,264.36
Rate for Payer: Anthem Medicare Advantage/PPO	$4,474.54
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,264.36
Rate for Payer: CareSource Just4Me Medicare	$6,040.63
Rate for Payer: Humana Medicare Advantage	$4,474.54
Rate for Payer: Molina Healthcare Benefit Exchange	$5,369.45

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$4,220.54

Service Code	CPT 52352
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

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

Facility

$6,264.36

Service Code	CPT 52346
Hospital Revenue Code	360
Min. Negotiated Rate	$4,474.54
Max. Negotiated Rate	$6,264.36
Rate for Payer: Anthem Medicare Advantage/PPO	$4,474.54
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,264.36
Rate for Payer: CareSource Just4Me Medicare	$6,040.63
Rate for Payer: Humana Medicare Advantage	$4,474.54
Rate for Payer: Molina Healthcare Benefit Exchange	$5,369.45

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

Facility

$4,220.54

Service Code	CPT 52344
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

CYSTOURETHRO W/ADDL IMPLANT

Professional

Both

$2,445.00

Service Code	HCPCS 52442
Hospital Charge Code	76102791
Hospital Revenue Code	761
Min. Negotiated Rate	$49.51
Max. Negotiated Rate	$2,445.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$50.53
Rate for Payer: Anthem Medicaid	$49.51
Rate for Payer: Buckeye Medicare Advantage	$2,445.00
Rate for Payer: Cash Price	$1,222.50
Rate for Payer: Cash Price	$1,222.50
Rate for Payer: Cigna Commercial	$101.11
Rate for Payer: Humana Medicaid	$49.51
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$82.62
Rate for Payer: Molina Healthcare CHIP/Medicaid	$50.50
Rate for Payer: Molina Healthcare Passport	$49.51
Rate for Payer: Multiplan PHCS	$1,467.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,711.50
Rate for Payer: UHCCP Medicaid	$53.06
Rate for Payer: Wellcare CHIP/Medicaid	$50.01

CYSTOURETHRO W/ADDL IMPLANT

Facility

$2,445.00

Service Code	HCPCS 52442
Hospital Charge Code	76102791
Hospital Revenue Code	761
Min. Negotiated Rate	$317.85
Max. Negotiated Rate	$2,347.20
Rate for Payer: Aetna Commercial	$1,882.65
Rate for Payer: Anthem POS/PPO/Traditional	$1,907.10
Rate for Payer: Cash Price	$1,222.50
Rate for Payer: Cigna Commercial	$2,029.35
Rate for Payer: First Health Commercial	$2,322.75
Rate for Payer: Humana Commercial	$2,078.25
Rate for Payer: Medical Mutual Of Ohio HMO	$2,004.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,804.41
Rate for Payer: Molina Healthcare Benefit Exchange	$733.50
Rate for Payer: Ohio Health Choice Commercial	$2,151.60
Rate for Payer: Ohio Health Group HMO	$1,833.75
Rate for Payer: Ohio Health Group PPO Differential	$489.00
Rate for Payer: Ohio Health Group PPO No Differential	$317.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$757.95
Rate for Payer: PHCS Commercial	$2,347.20
Rate for Payer: United Healthcare All Payer	$2,151.60

CYSTOURETHRO W/ADDL IMPLANT

Facility

$2,445.00

Service Code	HCPCS 52442
Hospital Charge Code	76102791
Hospital Revenue Code	761
Min. Negotiated Rate	$317.85
Max. Negotiated Rate	$2,347.20
Rate for Payer: Aetna Commercial	$1,882.65
Rate for Payer: Anthem Medicaid	$840.84
Rate for Payer: Anthem POS/PPO/Traditional	$1,907.10
Rate for Payer: Cash Price	$1,222.50
Rate for Payer: Cigna Commercial	$2,029.35
Rate for Payer: First Health Commercial	$2,322.75
Rate for Payer: Humana Commercial	$2,078.25
Rate for Payer: Humana KY Medicaid	$840.84
Rate for Payer: Kentucky WC Medicaid	$849.39
Rate for Payer: Medical Mutual Of Ohio HMO	$2,004.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,804.41
Rate for Payer: Molina Healthcare Benefit Exchange	$733.50
Rate for Payer: Molina Healthcare Medicaid	$857.71
Rate for Payer: Ohio Health Choice Commercial	$2,151.60
Rate for Payer: Ohio Health Group HMO	$1,833.75
Rate for Payer: Ohio Health Group PPO Differential	$489.00
Rate for Payer: Ohio Health Group PPO No Differential	$317.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$757.95
Rate for Payer: PHCS Commercial	$2,347.20
Rate for Payer: United Healthcare All Payer	$2,151.60

CYSTOURETHRO W/ADDL IMPLANT (P

Professional

Both

$880.00

Service Code	HCPCS 52442
Hospital Charge Code	761P2791
Hospital Revenue Code	761
Min. Negotiated Rate	$49.51
Max. Negotiated Rate	$880.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$50.53
Rate for Payer: Anthem Medicaid	$49.51
Rate for Payer: Buckeye Medicare Advantage	$880.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Cigna Commercial	$101.11
Rate for Payer: Humana Medicaid	$49.51
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$82.62
Rate for Payer: Molina Healthcare CHIP/Medicaid	$50.50
Rate for Payer: Molina Healthcare Passport	$49.51
Rate for Payer: Multiplan PHCS	$528.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$616.00
Rate for Payer: UHCCP Medicaid	$53.06
Rate for Payer: Wellcare CHIP/Medicaid	$50.01

CYSTOURETHRO W/ADDL IMPLANT (T

Facility

$1,565.00

Service Code	HCPCS 52442
Hospital Charge Code	761T2791
Hospital Revenue Code	761
Min. Negotiated Rate	$203.45
Max. Negotiated Rate	$1,502.40
Rate for Payer: Aetna Commercial	$1,205.05
Rate for Payer: Anthem Medicaid	$538.20
Rate for Payer: Anthem POS/PPO/Traditional	$1,220.70
Rate for Payer: Cash Price	$782.50
Rate for Payer: Cigna Commercial	$1,298.95
Rate for Payer: First Health Commercial	$1,486.75
Rate for Payer: Humana Commercial	$1,330.25
Rate for Payer: Humana KY Medicaid	$538.20
Rate for Payer: Kentucky WC Medicaid	$543.68
Rate for Payer: Medical Mutual Of Ohio HMO	$1,283.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,154.97
Rate for Payer: Molina Healthcare Benefit Exchange	$469.50
Rate for Payer: Molina Healthcare Medicaid	$549.00
Rate for Payer: Ohio Health Choice Commercial	$1,377.20
Rate for Payer: Ohio Health Group HMO	$1,173.75
Rate for Payer: Ohio Health Group PPO Differential	$313.00
Rate for Payer: Ohio Health Group PPO No Differential	$203.45
Rate for Payer: Ohio Health Group PPO SOMC Employees	$485.15
Rate for Payer: PHCS Commercial	$1,502.40
Rate for Payer: United Healthcare All Payer	$1,377.20

CYSTOURETHRO W/ADDL IMPLANT (T

Facility

$1,565.00

Service Code	HCPCS 52442
Hospital Charge Code	761T2791
Hospital Revenue Code	761
Min. Negotiated Rate	$203.45
Max. Negotiated Rate	$1,502.40
Rate for Payer: Aetna Commercial	$1,205.05
Rate for Payer: Anthem POS/PPO/Traditional	$1,220.70
Rate for Payer: Cash Price	$782.50
Rate for Payer: Cigna Commercial	$1,298.95
Rate for Payer: First Health Commercial	$1,486.75
Rate for Payer: Humana Commercial	$1,330.25
Rate for Payer: Medical Mutual Of Ohio HMO	$1,283.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,154.97
Rate for Payer: Molina Healthcare Benefit Exchange	$469.50
Rate for Payer: Ohio Health Choice Commercial	$1,377.20
Rate for Payer: Ohio Health Group HMO	$1,173.75
Rate for Payer: Ohio Health Group PPO Differential	$313.00
Rate for Payer: Ohio Health Group PPO No Differential	$203.45
Rate for Payer: Ohio Health Group PPO SOMC Employees	$485.15
Rate for Payer: PHCS Commercial	$1,502.40
Rate for Payer: United Healthcare All Payer	$1,377.20

CYSTOURETHRO W/IMPLANT

Professional

Both

$4,410.00

Service Code	HCPCS 52441
Hospital Charge Code	76102790
Hospital Revenue Code	761
Min. Negotiated Rate	$185.11
Max. Negotiated Rate	$4,410.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$189.33
Rate for Payer: Anthem Medicaid	$185.11
Rate for Payer: Buckeye Medicare Advantage	$4,410.00
Rate for Payer: Cash Price	$2,205.00
Rate for Payer: Cash Price	$2,205.00
Rate for Payer: Cigna Commercial	$377.94
Rate for Payer: Humana Medicaid	$185.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$308.85
Rate for Payer: Molina Healthcare CHIP/Medicaid	$188.81
Rate for Payer: Molina Healthcare Passport	$185.11
Rate for Payer: Multiplan PHCS	$2,646.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$3,087.00
Rate for Payer: UHCCP Medicaid	$198.80
Rate for Payer: Wellcare CHIP/Medicaid	$186.96

CYSTOURETHRO W/IMPLANT

Facility

$4,410.00

Service Code	HCPCS 52441
Hospital Charge Code	76102790
Hospital Revenue Code	761
Min. Negotiated Rate	$573.30
Max. Negotiated Rate	$4,233.60
Rate for Payer: Aetna Commercial	$3,395.70
Rate for Payer: Anthem Medicaid	$1,516.60
Rate for Payer: Anthem POS/PPO/Traditional	$3,439.80
Rate for Payer: Cash Price	$2,205.00
Rate for Payer: Cigna Commercial	$3,660.30
Rate for Payer: First Health Commercial	$4,189.50
Rate for Payer: Humana Commercial	$3,748.50
Rate for Payer: Humana KY Medicaid	$1,516.60
Rate for Payer: Kentucky WC Medicaid	$1,532.03
Rate for Payer: Medical Mutual Of Ohio HMO	$3,616.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,254.58
Rate for Payer: Molina Healthcare Benefit Exchange	$1,323.00
Rate for Payer: Molina Healthcare Medicaid	$1,547.03
Rate for Payer: Ohio Health Choice Commercial	$3,880.80
Rate for Payer: Ohio Health Group HMO	$3,307.50
Rate for Payer: Ohio Health Group PPO Differential	$882.00
Rate for Payer: Ohio Health Group PPO No Differential	$573.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,367.10
Rate for Payer: PHCS Commercial	$4,233.60
Rate for Payer: United Healthcare All Payer	$3,880.80

CYSTOURETHRO W/IMPLANT

Facility

$4,410.00

Service Code	HCPCS 52441
Hospital Charge Code	76102790
Hospital Revenue Code	761
Min. Negotiated Rate	$573.30
Max. Negotiated Rate	$4,233.60
Rate for Payer: Aetna Commercial	$3,395.70
Rate for Payer: Anthem POS/PPO/Traditional	$3,439.80
Rate for Payer: Cash Price	$2,205.00
Rate for Payer: Cigna Commercial	$3,660.30
Rate for Payer: First Health Commercial	$4,189.50
Rate for Payer: Humana Commercial	$3,748.50
Rate for Payer: Medical Mutual Of Ohio HMO	$3,616.20
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,254.58
Rate for Payer: Molina Healthcare Benefit Exchange	$1,323.00
Rate for Payer: Ohio Health Choice Commercial	$3,880.80
Rate for Payer: Ohio Health Group HMO	$3,307.50
Rate for Payer: Ohio Health Group PPO Differential	$882.00
Rate for Payer: Ohio Health Group PPO No Differential	$573.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,367.10
Rate for Payer: PHCS Commercial	$4,233.60
Rate for Payer: United Healthcare All Payer	$3,880.80

CYSTOURETHRO W/IMPLANT (P

Professional

Both

$1,280.00

Service Code	HCPCS 52441
Hospital Charge Code	761P2790
Hospital Revenue Code	761
Min. Negotiated Rate	$185.11
Max. Negotiated Rate	$1,280.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$189.33
Rate for Payer: Anthem Medicaid	$185.11
Rate for Payer: Buckeye Medicare Advantage	$1,280.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Cigna Commercial	$377.94
Rate for Payer: Humana Medicaid	$185.11
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$308.85
Rate for Payer: Molina Healthcare CHIP/Medicaid	$188.81
Rate for Payer: Molina Healthcare Passport	$185.11
Rate for Payer: Multiplan PHCS	$768.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$896.00
Rate for Payer: UHCCP Medicaid	$198.80
Rate for Payer: Wellcare CHIP/Medicaid	$186.96

CYSTOURETHRO W/IMPLANT (T

Facility

$3,130.00

Service Code	HCPCS 52441
Hospital Charge Code	761T2790
Hospital Revenue Code	761
Min. Negotiated Rate	$406.90
Max. Negotiated Rate	$3,004.80
Rate for Payer: Aetna Commercial	$2,410.10
Rate for Payer: Anthem Medicaid	$1,076.41
Rate for Payer: Anthem POS/PPO/Traditional	$2,441.40
Rate for Payer: Cash Price	$1,565.00
Rate for Payer: Cigna Commercial	$2,597.90
Rate for Payer: First Health Commercial	$2,973.50
Rate for Payer: Humana Commercial	$2,660.50
Rate for Payer: Humana KY Medicaid	$1,076.41
Rate for Payer: Kentucky WC Medicaid	$1,087.36
Rate for Payer: Medical Mutual Of Ohio HMO	$2,566.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,309.94
Rate for Payer: Molina Healthcare Benefit Exchange	$939.00
Rate for Payer: Molina Healthcare Medicaid	$1,098.00
Rate for Payer: Ohio Health Choice Commercial	$2,754.40
Rate for Payer: Ohio Health Group HMO	$2,347.50
Rate for Payer: Ohio Health Group PPO Differential	$626.00
Rate for Payer: Ohio Health Group PPO No Differential	$406.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$970.30
Rate for Payer: PHCS Commercial	$3,004.80
Rate for Payer: United Healthcare All Payer	$2,754.40

CYSTOURETHRO W/IMPLANT (T

Facility

$3,130.00

Service Code	HCPCS 52441
Hospital Charge Code	761T2790
Hospital Revenue Code	761
Min. Negotiated Rate	$406.90
Max. Negotiated Rate	$3,004.80
Rate for Payer: Aetna Commercial	$2,410.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,441.40
Rate for Payer: Cash Price	$1,565.00
Rate for Payer: Cigna Commercial	$2,597.90
Rate for Payer: First Health Commercial	$2,973.50
Rate for Payer: Humana Commercial	$2,660.50
Rate for Payer: Medical Mutual Of Ohio HMO	$2,566.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,309.94
Rate for Payer: Molina Healthcare Benefit Exchange	$939.00
Rate for Payer: Ohio Health Choice Commercial	$2,754.40
Rate for Payer: Ohio Health Group HMO	$2,347.50
Rate for Payer: Ohio Health Group PPO Differential	$626.00
Rate for Payer: Ohio Health Group PPO No Differential	$406.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$970.30
Rate for Payer: PHCS Commercial	$3,004.80
Rate for Payer: United Healthcare All Payer	$2,754.40

Know your out-of-pocket cost for care.

All Charges