|
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS
|
Facility
|
OP
|
$11,157.19
|
|
|
Service Code
|
CPT 52320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$11,157.19 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
CYSTOURETHROSCOPY (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 52000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$823.75
|
| Rate for Payer: AlohaCare Medicare |
$823.75
|
| Rate for Payer: Devoted Health Medicare |
$906.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$823.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$823.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$823.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$906.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$823.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$823.75
|
|
|
CYSTOURETHROSCOPY, WITH BIOPSY(S)
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52204
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,469.46
|
| Rate for Payer: AlohaCare Medicare |
$2,469.46
|
| Rate for Payer: Devoted Health Medicare |
$2,716.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,469.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$2,469.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,469.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,716.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,469.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,469.46
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
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
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52281
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,469.46
|
| Rate for Payer: AlohaCare Medicare |
$2,469.46
|
| Rate for Payer: Devoted Health Medicare |
$2,716.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,469.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$2,469.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,469.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,716.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,469.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,469.46
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52234
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52214
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52224
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,469.46
|
| Rate for Payer: AlohaCare Medicare |
$2,469.46
|
| Rate for Payer: Devoted Health Medicare |
$2,716.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,469.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$2,469.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,469.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,716.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,469.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,469.46
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52332
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED
|
Facility
|
OP
|
$7,917.66
|
|
|
Service Code
|
CPT 52284
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$7,917.66 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,917.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
|
|
CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE
|
Facility
|
OP
|
$11,157.19
|
|
|
Service Code
|
CPT 52310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$11,157.19 |
| Rate for Payer: AlohaCare Medicaid |
$2,469.46
|
| Rate for Payer: AlohaCare Medicare |
$2,469.46
|
| Rate for Payer: Devoted Health Medicare |
$2,716.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,469.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$2,469.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,469.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,716.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,469.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,469.46
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52341
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;
|
Facility
|
OP
|
$5,160.40
|
|
|
Service Code
|
CPT 52005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$2,469.46
|
| Rate for Payer: AlohaCare Medicare |
$2,469.46
|
| Rate for Payer: Devoted Health Medicare |
$2,716.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,469.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$2,469.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,469.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,716.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,469.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,469.46
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS
|
Facility
|
OP
|
$5,509.00
|
|
|
Service Code
|
CPT 52007
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,509.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52354
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$10,679.55
|
|
|
Service Code
|
CPT 52353
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$10,679.55 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$10,679.55
|
|
|
Service Code
|
CPT 52352
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$10,679.55 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$7,917.66
|
|
|
Service Code
|
CPT 52346
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$7,917.66 |
| Rate for Payer: AlohaCare Medicaid |
$6,334.13
|
| Rate for Payer: AlohaCare Medicare |
$6,334.13
|
| Rate for Payer: Devoted Health Medicare |
$6,967.54
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,917.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,334.13
|
| Rate for Payer: Humana Medicare |
$6,334.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,334.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,967.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,334.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,334.13
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 52344
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 52345
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,164.22
|
| Rate for Payer: AlohaCare Medicare |
$4,164.22
|
| Rate for Payer: Devoted Health Medicare |
$4,580.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,164.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$4,164.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,164.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,580.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,164.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,164.22
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [96982]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J9100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
