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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
$5,110 / 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.

$5,110

Without insurance

What goes into a price?

Negotiated prices across insurers

Lowest
$977
Highest
$12,498
Cash price
up to $5,110

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 C1894 Facility Fee Insertion of Non-intracardiac Diagnostic/Therapeutic Device/Sheath
HCPCS C1769 Facility Fee Controlled Insertion of Thin Wire for Diagnostic Mapping
HCPCS J3010 Facility Fee Intramuscular injection of fentanyl citrate, 0.1mg
HCPCS 52353 Professional Fee Ureteroscopy, Pyeloscopy, Lithotripsy with Cystourethroscopy
HCPCS C1889 Facility Fee Implantable/insertable Device of Unspecified Type
HCPCS J0690 Facility Fee Intramuscular injection cefazolin sodium, 500mg
HCPCS J2405 Facility Fee Intramuscular injection of ondansetron hydrochloride, 1mg
HCPCS J1100 Facility Fee Intramuscular injection of 1mg dexamethasone sodium phosphate
HCPCS 52353 Facility Fee Ureteroscopy, Pyeloscopy, Lithotripsy with Cystourethroscopy
Revenue Code 250 Facility Fee Pharmacy (Also see 063X, an extension of 250X) - General
HCPCS A9900 Facility Fee Additional Equipment or Service for Medical Supplies Under Specific Code

Disclaimer

Hawaii Health Systems Corporation 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
$5,110 / 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

Hawaii Health Systems Corporation 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 C1894, HCPCS C1769, HCPCS J3010, HCPCS 52353, HCPCS C1889
Insurance I'm not using insurance
Location Hilo Benioff Medical Center Main
When you contact us, you can say:
"Hi, I'm calling to verify a price for Kidney stone removal and cystourethroscopy I found through Hilo Benioff Medical Center Main's price estimate tool. Here are the codes I’m looking at: HCPCS C1894, HCPCS C1769, HCPCS J3010, HCPCS 52353, HCPCS C1889. I'm not using insurance, can you confirm the cash pay estimate and help me schedule if needed?"
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