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Package

Kidney stone removal and cystourethroscopy

Package

Kidney stone removal and cystourethroscopy

Kidney stone removal and cystourethroscopy uses a thin, flexible camera inserted through the urethra to examine the bladder and urinary tract and remove kidney stones causing pain or blockage. The doctor may use specialized tools to break up or extract the stones during the same procedure. Most patients go home the same day and experience improved symptoms shortly after. Your doctor will advise on preparation and recovery, including hydration recommendations and temporary activity limits.
You'd pay up to
$17,163 / Case Rate

A single, all-inclusive pricing methodology for a procedure in healthcare contracts, instead of separate charges for each service.

The estimated total cost of care without any insurance coverage or discounts.

$17,163

Without insurance

What goes into a price?

Negotiated prices across insurers

Lowest
$8,179
Highest
$25,403
Cash price
up to $17,163

Self pay or cash prices vary by facility when paying out of pocket without insurance benefits. The chart shows you how the lowest and highest amounts facilities charge for this service if you were paying without insurance benefits. If you're uninsured or not submitting a claim to insurance, you also have the right to a Good Faith Estimate under federal law. Contact the provider for a copy of your Good Faith Estimate or to better understand payment options available to you.

Procedures included in this package

This list includes the services and fees bundled into the Kidney stone removal and cystourethroscopy Standard Service Package (SSP UR000). The final price for the procedure will depend on which services your provider ultimately performs, your insurance plan and your medical benefits.

Code Code Type Description
HCPCS C1769 Facility Fee Controlled Insertion of Thin Wire for Diagnostic Mapping
HCPCS J7030 Facility Fee Intravenous infusion of 1000cc of normal saline
HCPCS J1100 Facility Fee Intramuscular injection of 1mg dexamethasone sodium phosphate
HCPCS J2405 Facility Fee Intramuscular injection of ondansetron hydrochloride, 1mg
HCPCS J0690 Facility Fee Intramuscular injection cefazolin sodium, 500mg
HCPCS Q9967 Facility Fee Non-ionic low osmolar contrast, 300-399mg/ml iodine concentration per ml
HCPCS J2704 Facility Fee Intramuscular injection of 10mg propofol
HCPCS J3010 Facility Fee Intramuscular injection of fentanyl citrate, 0.1mg
HCPCS 74018 Facility Fee X-ray of abdomen, 1 view
HCPCS 52353 Facility Fee Ureteroscopy, Pyeloscopy, Lithotripsy with Cystourethroscopy
HCPCS 52353 Professional Fee Ureteroscopy, Pyeloscopy, Lithotripsy with Cystourethroscopy
Revenue Code 250 Facility Fee Pharmacy (Also see 063X, an extension of 250X) - General
HCPCS J2001 Facility Fee Injection of 10mg Lidocaine Hcl via IV Infusion
HCPCS 74420 Professional Fee X-ray Imaging of Urinary Tract Using Both Antegrade and Retrograde Techniques

Disclaimer

Southern Ohio Medical Center is committed to empowering our patients to make informed decisions about their healthcare. This includes helping patients understand the cost of care and the availability of financial assistance.

In compliance with federal law, we provide a list of standard charges that are reviewed on an annual basis. Charges for hospital services are not equivalent to the actual amount paid by insurance companies or patients. The amount paid for services is based on many factors, including health insurance benefit plans, applicable discounts, and services provided based on each patient's unique needs.

You'd pay up to
$17,163 / Case Rate

A single, all-inclusive pricing methodology for a procedure in healthcare contracts, instead of separate charges for each service.

The estimated total cost of care without any insurance coverage or discounts.

Disclaimer

Southern Ohio Medical Center is committed to empowering our patients to make informed decisions about their healthcare. This includes helping patients understand the cost of care and the availability of financial assistance.

In compliance with federal law, we provide a list of standard charges that are reviewed on an annual basis. Charges for hospital services are not equivalent to the actual amount paid by insurance companies or patients. The amount paid for services is based on many factors, including health insurance benefit plans, applicable discounts, and services provided based on each patient's unique needs.

What’s the difference between an individual procedure and a Standard Service Package (SSP)?

Individual Procedure

Individual procedures, like blood tests, each have unique prices and billing codes (like a CPT or HCPCS code). While they can be billed alone, they're usually grouped with other procedures on a claim. This grouping is what determines the total cost of your care.

Standard Service Package (SSP)

A SSP combines all medical services, materials, and fees associated with a healthcare visit or procedure into a single bundle to offer a more comprehensive estimate.

Contact us to verify your estimate

Have your service name, codes, and payment preference ready. If you’re using insurance, you may be asked for insurance details like your Member or Group ID.

Service Kidney stone removal and cystourethroscopy
Service Codes HCPCS C1769, HCPCS J7030, HCPCS J1100, HCPCS J2405, HCPCS J0690
Insurance I'm not using insurance
Location Southern Ohio Medical Center
When you contact us, you can say:
"Hi, I'm calling to verify a price for Kidney stone removal and cystourethroscopy I found through Southern Ohio Medical Center's price estimate tool. Here are the codes I’m looking at: HCPCS C1769, HCPCS J7030, HCPCS J1100, HCPCS J2405, HCPCS J0690. I'm not using insurance, can you confirm the cash pay estimate and help me schedule if needed?"
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