Top Self-Pay and ASC Rates
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Professional Physician Patient Responsibility |
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| CPT | Procedure Description | Due from Patient Office Setting |
Due from Patient
Facility Setting (ASC or Hospital) |
| 36415 | Routine venipuncture | $ 11.00 | $ 11.00 |
| 51728 | Cystometrogram w/vp | $ 480.00 | $ 129.00 |
| 51741 | Electro-uroflowmetry first | $ 18.00 | $ 11.00 |
| 51798 | Us urine capacity measure | $ 14.00 | $ 14.00 |
| 52000 | Cystoscopy | $ 316.00 | $ 100.00 |
| 76770 | Us exam abdo back wall comp | $ 143.00 | $ - |
| 76775 | Us exam abdo back wall lim | $ 77.00 | $ - |
| 76856 | Us exam pelvic complete | $ 140.00 | $ - |
| 76872 | Us transrectal | $ 181.00 | $ 41.00 |
| 77014 | Ct scan for therapy guide | $ 158.00 | $ 158.00 |
| 81003 | Urinalysis auto w/o scope | $ 3.00 | $ 3.00 |
| 96372 | Ther/proph/diag inj sc/im | $ 18.00 | $ 18.00 |
| ESTSELF | Established Office Visit (Includes 99214 OV, Bladder Scan 51798, Blood Draw 36415 & UA 81003) | $ 191.00 | $ 191.00 |
| G6015 | Radiation tx delivery imrt | $ 479.00 | $ 479.00 |
| NEWSELF | New Office Visit (Includes 99204 OV, Bladder Scan 51798, Blood Draw 36415 & UA 81003) | $ 240.00 | $ 240.00 |
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ASC Facility Patient Responsibility |
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| CPT | Procedure Description | PI | Self Pay ASC Rate |
| 52000 | Cystoscopy | A2 | $ 356.00 |
| 55700 | Biopsy of prostate | A2 | $ 1,067.00 |
| 55250 | Removal of sperm duct(s) | A2 | $ 1,067.00 |
| 76872 | Us transrectal | Z2 | $ 70.00 |
| 52310 | Cystoscopy and treatment | A2 | $ 1,067.00 |
| 52356 | Cysto/uretero w/lithotripsy | G2 | $ 2,847.00 |
| 52287 | Cystoscopy chemodenervation | G2 | $ 1,067.00 |
| J0585 | Injection,onabotulinumtoxina | K2 | $ 8.00 |
| 64561 | Implant neuroelectrodes | J8 | $ 6,275.00 |
| 52332 | Cystoscopy and treatment | A2 | $ 1,882.00 |
| 74420 | Urography rtrgr +-kub | Z2 | $ 241.00 |
| 52281 | Cystoscopy and treatment | A2 | $ 1,067.00 |
| 52648 | Laser surgery of prostate | A2 | $ 2,847.00 |
| 52601 | Prostatectomy (turp) | A2 | $ 2,847.00 |
| 50590 | Fragmenting of kidney stone | G2 | $ 1,882.00 |
| 52351 | Cystouretero & or pyeloscope | A2 | $ 1,882.00 |
| 52352 | Cystouretero w/stone remove | A2 | $ 1,882.00 |
| 51715 | Endoscopic injection/implant | J8 | $ 2,567.00 |
| 52234 | Cystoscopy and treatment | A2 | $ 1,882.00 |
| 52204 | Cystoscopy w/biopsy(s) | A2 | $ 1,067.00 |
| 52235 | Cystoscopy and treatment | A2 | $ 1,882.00 |
| 64590 | Insrt/redo pn/gastr stimul | J8 | $ 24,319.00 |
| 50081 | Perq nl/pl lithotrp cplx>2cm | G2 | $ 5,384.00 |
| 54161 | Circum 28 days or older | A2 | $ 1,067.00 |
| C9740 4 clips | Cysto impl 4 or more | J8 | $ 9,265.00 |
| C9740 5 clips | Cysto impl 4 or more | J8 | $ 9,311.00 |
| C9740 6 clips | Cysto impl 4 or more | J8 | $ 9,357.00 |
| C9740 7 clips | Cysto impl 4 or more | J8 | $ 9,403.00 |
THE HEALTH CARE PRICE FOR ANY GIVEN HEALTH CARE SERVICE IS AN ESTIMATE AND THAT THE ACTUAL CHARGES FOR THE HEALTH CARE SERVICE ARE DEPENDENT ON THE CIRCUMSTANCES AT THE TIME THE SERVICE IS RENDERED.
IF YOU ARE COVERED BY HEALTH INSURANCE, YOU ARE STRONGLY ENCOURAGED TO CONSULT WITH YOUR HEALTH INSURER TO DETERMINE ACCURATE INFORMATION ABOUT YOUR FINANCIAL RESPONSIBILITY FOR A PARTICULAR HEALTH CARE SERVICE PROVIDED BY A HEALTH CARE PROVIDER AT THIS OFFICE. IF YOU ARE NOT COVERED BY HEALTH INSURANCE, YOU ARE STRONGLY ENCOURAGED TO CONTACT OUR PATIENT LIASON AT 866-681-2335 TO DISCUSS PAYMENT OPTIONS PRIOR TO RECEIVING A HEALTH CARE SERVICE FROM A HEALTH CARE PROVIDER AT THIS OFFICE SINCE POSTED HEALTH CARE PRICES MAY NOT REFLECT THE ACTUAL AMOUNT OF YOUR FINANCIAL RESPONSIBILITY.