Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CYSTOURETHROSCOPY SEP PX(T

Facility

$3,855.00

Service Code	HCPCS 52000
Hospital Charge Code	761T2081
Hospital Revenue Code	761
Min. Negotiated Rate	$1,156.50
Max. Negotiated Rate	$3,700.80
Rate for Payer: Aetna Commercial	$2,968.35
Rate for Payer: Anthem POS/PPO/Traditional	$3,006.90
Rate for Payer: Cash Price	$1,927.50
Rate for Payer: Cigna Commercial	$3,199.65
Rate for Payer: First Health Commercial	$3,662.25
Rate for Payer: Humana Commercial	$3,276.75
Rate for Payer: Medical Mutual Of Ohio HMO	$3,161.10
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,844.99
Rate for Payer: Molina Healthcare Benefit Exchange	$1,156.50
Rate for Payer: Ohio Health Choice Commercial	$3,392.40
Rate for Payer: Ohio Health Group HMO	$2,891.25
Rate for Payer: Ohio Health Group PPO Differential	$3,084.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,353.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,659.95
Rate for Payer: PHCS Commercial	$3,700.80
Rate for Payer: United Healthcare All Payer	$3,392.40

CYSTOURETHROSCOPY, W/BIOPSY(S)

Facility

$6,129.64

Service Code	HCPCS 52204
Hospital Charge Code	76102084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$5,884.45
Rate for Payer: Aetna Commercial	$4,719.82
Rate for Payer: Anthem Medicaid	$2,107.98
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Anthem POS/PPO/Traditional	$4,781.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Cash Price	$3,064.82
Rate for Payer: Cash Price	$3,064.82
Rate for Payer: Cigna Commercial	$5,087.60
Rate for Payer: First Health Commercial	$5,823.16
Rate for Payer: Humana Commercial	$5,210.19
Rate for Payer: Humana KY Medicaid	$2,107.98
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Kentucky WC Medicaid	$2,129.44
Rate for Payer: Medical Mutual Of Ohio HMO	$5,026.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,523.67
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34
Rate for Payer: Molina Healthcare Medicaid	$2,150.28
Rate for Payer: Ohio Health Choice Commercial	$5,394.08
Rate for Payer: Ohio Health Group HMO	$4,597.23
Rate for Payer: Ohio Health Group PPO Differential	$4,903.71
Rate for Payer: Ohio Health Group PPO No Differential	$5,332.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,229.45
Rate for Payer: PHCS Commercial	$5,884.45
Rate for Payer: United Healthcare All Payer	$5,394.08

CYSTOURETHROSCOPY, W/BIOPSY(S)

Facility

$5,329.64

Service Code	HCPCS 52204
Hospital Charge Code	761T2084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,832.86
Max. Negotiated Rate	$5,116.45
Rate for Payer: Aetna Commercial	$4,103.82
Rate for Payer: Anthem Medicaid	$1,832.86
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Anthem POS/PPO/Traditional	$4,157.12
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Cash Price	$2,664.82
Rate for Payer: Cash Price	$2,664.82
Rate for Payer: Cigna Commercial	$4,423.60
Rate for Payer: First Health Commercial	$5,063.16
Rate for Payer: Humana Commercial	$4,530.19
Rate for Payer: Humana KY Medicaid	$1,832.86
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Kentucky WC Medicaid	$1,851.52
Rate for Payer: Medical Mutual Of Ohio HMO	$4,370.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,933.27
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34
Rate for Payer: Molina Healthcare Medicaid	$1,869.64
Rate for Payer: Ohio Health Choice Commercial	$4,690.08
Rate for Payer: Ohio Health Group HMO	$3,997.23
Rate for Payer: Ohio Health Group PPO Differential	$4,263.71
Rate for Payer: Ohio Health Group PPO No Differential	$4,636.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,677.45
Rate for Payer: PHCS Commercial	$5,116.45
Rate for Payer: United Healthcare All Payer	$4,690.08

CYSTOURETHROSCOPY, W/BIOPSY(S)

Facility

$5,329.64

Service Code	HCPCS 52204
Hospital Charge Code	761T2084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,598.89
Max. Negotiated Rate	$5,116.45
Rate for Payer: Aetna Commercial	$4,103.82
Rate for Payer: Anthem POS/PPO/Traditional	$4,157.12
Rate for Payer: Cash Price	$2,664.82
Rate for Payer: Cigna Commercial	$4,423.60
Rate for Payer: First Health Commercial	$5,063.16
Rate for Payer: Humana Commercial	$4,530.19
Rate for Payer: Medical Mutual Of Ohio HMO	$4,370.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,933.27
Rate for Payer: Molina Healthcare Benefit Exchange	$1,598.89
Rate for Payer: Ohio Health Choice Commercial	$4,690.08
Rate for Payer: Ohio Health Group HMO	$3,997.23
Rate for Payer: Ohio Health Group PPO Differential	$4,263.71
Rate for Payer: Ohio Health Group PPO No Differential	$4,636.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,677.45
Rate for Payer: PHCS Commercial	$5,116.45
Rate for Payer: United Healthcare All Payer	$4,690.08

CYSTOURETHROSCOPY, W/BIOPSY(S)

Professional

Both

$6,129.64

Service Code	HCPCS 52204
Hospital Charge Code	76102084
Hospital Revenue Code	761
Min. Negotiated Rate	$107.63
Max. Negotiated Rate	$3,677.78
Rate for Payer: Aetna Commercial	$232.28
Rate for Payer: Ambetter Exchange	$132.70
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$107.63
Rate for Payer: Anthem Medicaid	$139.21
Rate for Payer: Buckeye Individual/Medicaid	$132.70
Rate for Payer: Buckeye Medicare Advantage	$132.70
Rate for Payer: CareSource Just4Me Medicare	$159.24
Rate for Payer: Cash Price	$3,064.82
Rate for Payer: Cash Price	$3,064.82
Rate for Payer: Cigna Commercial	$204.01
Rate for Payer: Healthspan PPO	$549.49
Rate for Payer: Humana Medicaid	$139.21
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$193.26
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$132.70
Rate for Payer: Molina Healthcare Benefit Exchange	$132.70
Rate for Payer: Molina Healthcare CHIP/Medicaid	$141.99
Rate for Payer: Molina Healthcare Passport	$139.21
Rate for Payer: Multiplan PHCS	$3,677.78
Rate for Payer: Ohio Health Choice Preferred Health Choice	$172.51
Rate for Payer: UHCCP Medicaid	$113.01
Rate for Payer: Wellcare CHIP/Medicaid	$140.60
Rate for Payer: Wellcare Medicare Advantage	$132.70

CYSTOURETHROSCOPY, W/BIOPSY(S)

Professional

Both

$800.00

Service Code	HCPCS 52204
Hospital Charge Code	761P2084
Hospital Revenue Code	761
Min. Negotiated Rate	$107.63
Max. Negotiated Rate	$549.49
Rate for Payer: Aetna Commercial	$232.28
Rate for Payer: Ambetter Exchange	$132.70
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$107.63
Rate for Payer: Anthem Medicaid	$139.21
Rate for Payer: Buckeye Individual/Medicaid	$132.70
Rate for Payer: Buckeye Medicare Advantage	$132.70
Rate for Payer: CareSource Just4Me Medicare	$159.24
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cigna Commercial	$204.01
Rate for Payer: Healthspan PPO	$549.49
Rate for Payer: Humana Medicaid	$139.21
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$193.26
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$132.70
Rate for Payer: Molina Healthcare Benefit Exchange	$132.70
Rate for Payer: Molina Healthcare CHIP/Medicaid	$141.99
Rate for Payer: Molina Healthcare Passport	$139.21
Rate for Payer: Multiplan PHCS	$480.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$172.51
Rate for Payer: UHCCP Medicaid	$113.01
Rate for Payer: Wellcare CHIP/Medicaid	$140.60
Rate for Payer: Wellcare Medicare Advantage	$132.70

CYSTOURETHROSCOPY, W/BIOPSY(S)

Facility

$6,129.64

Service Code	HCPCS 52204
Hospital Charge Code	76102084
Hospital Revenue Code	761
Min. Negotiated Rate	$1,838.89
Max. Negotiated Rate	$5,884.45
Rate for Payer: Aetna Commercial	$4,719.82
Rate for Payer: Anthem POS/PPO/Traditional	$4,781.12
Rate for Payer: Cash Price	$3,064.82
Rate for Payer: Cigna Commercial	$5,087.60
Rate for Payer: First Health Commercial	$5,823.16
Rate for Payer: Humana Commercial	$5,210.19
Rate for Payer: Medical Mutual Of Ohio HMO	$5,026.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,523.67
Rate for Payer: Molina Healthcare Benefit Exchange	$1,838.89
Rate for Payer: Ohio Health Choice Commercial	$5,394.08
Rate for Payer: Ohio Health Group HMO	$4,597.23
Rate for Payer: Ohio Health Group PPO Differential	$4,903.71
Rate for Payer: Ohio Health Group PPO No Differential	$5,332.79
Rate for Payer: Ohio Health Group PPO SOMC Employees	$4,229.45
Rate for Payer: PHCS Commercial	$5,884.45
Rate for Payer: United Healthcare All Payer	$5,394.08

CYSTOURETHROSCOPY, WITH BIOPSY(S)

Facility

$2,649.89

Service Code	CPT 52204
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE

Facility

$2,649.89

Service Code	CPT 52281
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY

Facility

$2,649.89

Service Code	CPT 52276
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)

Facility

$6,576.02

Service Code	CPT 52240
Hospital Revenue Code	360
Min. Negotiated Rate	$4,697.16
Max. Negotiated Rate	$6,576.02
Rate for Payer: Anthem Medicare Advantage/PPO	$4,697.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,576.02
Rate for Payer: CareSource Just4Me Medicare	$6,341.17
Rate for Payer: Humana Medicare Advantage	$4,697.16
Rate for Payer: Molina Healthcare Benefit Exchange	$5,636.59

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)

Facility

$4,461.49

Service Code	CPT 52235
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)

Facility

$4,461.49

Service Code	CPT 52234
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS

Facility

$4,461.49

Service Code	CPT 52214
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY

Facility

$4,461.49

Service Code	CPT 52224
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

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

Facility

$2,649.89

Service Code	CPT 52287
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

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

Facility

$4,461.49

Service Code	CPT 52332
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

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

Facility

$11,961.85

Service Code	CPT C9740
Hospital Revenue Code	360
Min. Negotiated Rate	$8,544.18
Max. Negotiated Rate	$11,961.85
Rate for Payer: Anthem Medicare Advantage/PPO	$8,544.18
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,961.85
Rate for Payer: CareSource Just4Me Medicare	$11,534.64
Rate for Payer: Humana Medicare Advantage	$8,544.18
Rate for Payer: Molina Healthcare Benefit Exchange	$10,253.02

CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS

Facility

$4,461.49

Service Code	CPT 52001
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

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

Facility

$2,649.89

Service Code	CPT 52310
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

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

Facility

$2,649.89

Service Code	CPT 52005
Hospital Revenue Code	360
Min. Negotiated Rate	$1,892.78
Max. Negotiated Rate	$2,649.89
Rate for Payer: Anthem Medicare Advantage/PPO	$1,892.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,649.89
Rate for Payer: CareSource Just4Me Medicare	$2,555.25
Rate for Payer: Humana Medicare Advantage	$1,892.78
Rate for Payer: Molina Healthcare Benefit Exchange	$2,271.34

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$4,461.49

Service Code	CPT 52351
Hospital Revenue Code	360
Min. Negotiated Rate	$3,186.78
Max. Negotiated Rate	$4,461.49
Rate for Payer: Anthem Medicare Advantage/PPO	$3,186.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,461.49
Rate for Payer: CareSource Just4Me Medicare	$4,302.15
Rate for Payer: Humana Medicare Advantage	$3,186.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,824.14

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

Facility

$6,576.02

Service Code	CPT 52354
Hospital Revenue Code	360
Min. Negotiated Rate	$4,697.16
Max. Negotiated Rate	$6,576.02
Rate for Payer: Anthem Medicare Advantage/PPO	$4,697.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,576.02
Rate for Payer: CareSource Just4Me Medicare	$6,341.17
Rate for Payer: Humana Medicare Advantage	$4,697.16
Rate for Payer: Molina Healthcare Benefit Exchange	$5,636.59

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

Facility

$6,576.02

Service Code	CPT 52356
Hospital Revenue Code	360
Min. Negotiated Rate	$4,697.16
Max. Negotiated Rate	$6,576.02
Rate for Payer: Anthem Medicare Advantage/PPO	$4,697.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,576.02
Rate for Payer: CareSource Just4Me Medicare	$6,341.17
Rate for Payer: Humana Medicare Advantage	$4,697.16
Rate for Payer: Molina Healthcare Benefit Exchange	$5,636.59

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

Facility

$6,576.02

Service Code	CPT 52353
Hospital Revenue Code	360
Min. Negotiated Rate	$4,697.16
Max. Negotiated Rate	$6,576.02
Rate for Payer: Anthem Medicare Advantage/PPO	$4,697.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$6,576.02
Rate for Payer: CareSource Just4Me Medicare	$6,341.17
Rate for Payer: Humana Medicare Advantage	$4,697.16
Rate for Payer: Molina Healthcare Benefit Exchange	$5,636.59

Know your out-of-pocket cost for care.

All Charges