|
52344 Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture
|
Professional
|
Both
|
$4,906.00
|
|
|
Service Code
|
HCPCS 52344
|
| Hospital Charge Code |
8039726
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$321.11 |
| Max. Negotiated Rate |
$4,170.10 |
| Rate for Payer: AlohaCare Medicaid |
$364.52
|
| Rate for Payer: AlohaCare Medicare |
$321.11
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Devoted Health Medicare |
$353.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$321.11
|
| Rate for Payer: Health Management Network Commercial |
$4,170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$353.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$353.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$353.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$364.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$321.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$364.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$321.11
|
|
|
52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic
|
Professional
|
Both
|
$4,906.00
|
|
|
Service Code
|
HCPCS 52351
|
| Hospital Charge Code |
8039727
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$264.15 |
| Max. Negotiated Rate |
$4,170.10 |
| Rate for Payer: AlohaCare Medicaid |
$299.13
|
| Rate for Payer: AlohaCare Medicare |
$264.15
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Devoted Health Medicare |
$290.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$264.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$329.94
|
| Rate for Payer: Health Management Network Commercial |
$4,170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$290.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$290.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$299.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$264.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$299.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$264.15
|
|
|
52352 Cystourethroscopy with ureteroscopy and/or pyeloscopy with removal or manipulation of calculus
|
Professional
|
Both
|
$4,906.00
|
|
|
Service Code
|
HCPCS 52352
|
| Hospital Charge Code |
8039728
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$308.37 |
| Max. Negotiated Rate |
$4,170.10 |
| Rate for Payer: AlohaCare Medicaid |
$349.39
|
| Rate for Payer: AlohaCare Medicare |
$308.37
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Devoted Health Medicare |
$339.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$308.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$410.54
|
| Rate for Payer: Health Management Network Commercial |
$4,170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$339.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$349.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$308.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$349.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$308.37
|
|
|
52353 Cystourethroscopy with ureteroscopy and/or pyeloscopy with lithotripsy
|
Professional
|
Both
|
$7,462.00
|
|
|
Service Code
|
HCPCS 52353
|
| Hospital Charge Code |
8039729
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$340.00 |
| Max. Negotiated Rate |
$6,342.70 |
| Rate for Payer: AlohaCare Medicaid |
$386.17
|
| Rate for Payer: AlohaCare Medicare |
$340.00
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Devoted Health Medicare |
$374.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$340.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$475.80
|
| Rate for Payer: Health Management Network Commercial |
$6,342.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$374.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$374.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$374.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$386.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$340.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$386.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$340.00
|
|
|
52356 CYSTO/URETERO W/LITHOTRIPSY
|
Facility
|
IP
|
$7,325.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
8725738
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,226.25 |
| Max. Negotiated Rate |
$7,105.25 |
| Rate for Payer: Cash Price |
$4,761.25
|
| Rate for Payer: Health Management Network Commercial |
$6,226.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,592.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,105.25
|
|
|
52356 CYSTO/URETERO W/LITHOTRIPSY
|
Facility
|
OP
|
$7,325.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
8725738
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$11,157.19 |
| Rate for Payer: AlohaCare Medicaid |
$3,662.50
|
| Rate for Payer: AlohaCare Medicare |
$3,662.50
|
| Rate for Payer: Cash Price |
$4,761.25
|
| Rate for Payer: Cash Price |
$4,761.25
|
| Rate for Payer: Devoted Health Medicare |
$4,028.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11,119.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,662.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,154.45
|
| Rate for Payer: Health Management Network Commercial |
$6,226.25
|
| Rate for Payer: Humana Medicare |
$3,662.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,592.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,662.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,105.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,662.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,662.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,662.50
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
52356 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INS ProFee
|
Professional
|
Both
|
$7,462.00
|
|
|
Service Code
|
HCPCS 52356
|
| Hospital Charge Code |
8020711
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$360.38 |
| Max. Negotiated Rate |
$6,342.70 |
| Rate for Payer: AlohaCare Medicaid |
$409.29
|
| Rate for Payer: AlohaCare Medicare |
$360.38
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Devoted Health Medicare |
$396.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$360.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$432.90
|
| Rate for Payer: Health Management Network Commercial |
$6,342.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$396.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$396.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$396.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$409.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$360.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$409.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$360.38
|
|
|
52500 Transurethral resection of bladder neck (separate procedure)
|
Professional
|
Both
|
$4,906.00
|
|
|
Service Code
|
HCPCS 52500
|
| Hospital Charge Code |
8039734
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$359.72 |
| Max. Negotiated Rate |
$4,170.10 |
| Rate for Payer: AlohaCare Medicaid |
$506.68
|
| Rate for Payer: AlohaCare Medicare |
$359.72
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Cash Price |
$3,188.90
|
| Rate for Payer: Devoted Health Medicare |
$395.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$359.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$606.06
|
| Rate for Payer: Health Management Network Commercial |
$4,170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$395.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$395.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$395.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$506.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$359.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$506.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$359.72
|
|
|
52601 Transurethral electrosurgical resection of prostate, incld control of postoperative bleeding
|
Professional
|
Both
|
$7,462.00
|
|
|
Service Code
|
HCPCS 52601
|
| Hospital Charge Code |
8039735
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$530.04 |
| Max. Negotiated Rate |
$6,342.70 |
| Rate for Payer: AlohaCare Medicaid |
$734.33
|
| Rate for Payer: AlohaCare Medicare |
$530.04
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Cash Price |
$4,850.30
|
| Rate for Payer: Devoted Health Medicare |
$583.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$530.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.62
|
| Rate for Payer: Health Management Network Commercial |
$6,342.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$583.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$583.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$583.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$734.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$530.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$734.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$530.04
|
|
|
53620-Dilation Urethral Stricture Filiform Male
|
Facility
|
IP
|
$3,472.00
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
8080230
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,951.20 |
| Max. Negotiated Rate |
$3,367.84 |
| Rate for Payer: Cash Price |
$2,256.80
|
| Rate for Payer: Health Management Network Commercial |
$2,951.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,124.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,367.84
|
|
|
53620-Dilation Urethral Stricture Filiform Male
|
Facility
|
OP
|
$3,472.00
|
|
|
Service Code
|
HCPCS 53620
|
| Hospital Charge Code |
8080230
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$3,367.84 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$1,736.00
|
| Rate for Payer: Cash Price |
$2,256.80
|
| Rate for Payer: Cash Price |
$2,256.80
|
| Rate for Payer: Cash Price |
$2,256.80
|
| Rate for Payer: Devoted Health Medicare |
$1,909.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,736.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,298.40
|
| Rate for Payer: Health Management Network Commercial |
$2,951.20
|
| Rate for Payer: Humana Medicare |
$1,736.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,124.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,736.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,367.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,736.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,736.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,736.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,530.74
|
|
|
54050 Destruction of lesion(s), penis, simple; chemicall
|
Professional
|
Both
|
$566.00
|
|
|
Service Code
|
HCPCS 54050
|
| Hospital Charge Code |
8039765
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$481.10 |
| Rate for Payer: AlohaCare Medicaid |
$114.20
|
| Rate for Payer: AlohaCare Medicare |
$101.76
|
| Rate for Payer: Cash Price |
$367.90
|
| Rate for Payer: Cash Price |
$367.90
|
| Rate for Payer: Devoted Health Medicare |
$111.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$114.20
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$183.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$101.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$114.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.92
|
| Rate for Payer: Health Management Network Commercial |
$481.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$101.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$101.76
|
| Rate for Payer: University Health Alliance Commercial |
$144.21
|
|
|
54055 Destruction of lesion(s), penis, simple; electrodesiccation
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 54055
|
| Hospital Charge Code |
8039766
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$101.78
|
| Rate for Payer: AlohaCare Medicare |
$90.55
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$99.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$101.78
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$162.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$90.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$101.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.50
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$101.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$90.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$90.55
|
| Rate for Payer: University Health Alliance Commercial |
$127.97
|
|
|
54056 Destruction of lesion(s), penis, simple; cryosurgery
|
Professional
|
Both
|
$421.00
|
|
|
Service Code
|
HCPCS 54056
|
| Hospital Charge Code |
8039767
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$357.85 |
| Rate for Payer: AlohaCare Medicaid |
$120.14
|
| Rate for Payer: AlohaCare Medicare |
$104.60
|
| Rate for Payer: Cash Price |
$273.65
|
| Rate for Payer: Cash Price |
$273.65
|
| Rate for Payer: Devoted Health Medicare |
$115.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$120.14
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$192.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$104.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$120.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.50
|
| Rate for Payer: Health Management Network Commercial |
$357.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$115.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$104.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$104.60
|
| Rate for Payer: University Health Alliance Commercial |
$150.85
|
|
|
54060 Destruction of lesion(s), penis, simple; surgical excision
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 54060
|
| Hospital Charge Code |
8039768
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$137.32
|
| Rate for Payer: AlohaCare Medicare |
$126.07
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$138.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$137.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$223.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$137.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.50
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$138.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$138.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$137.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$137.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.07
|
| Rate for Payer: University Health Alliance Commercial |
$176.39
|
|
|
54065 Destruction of lesion(s), penis, extensive; cryosurgery
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 54065
|
| Hospital Charge Code |
8039769
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$155.59 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$180.40
|
| Rate for Payer: AlohaCare Medicare |
$155.59
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$171.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$180.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$293.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$180.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.58
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$171.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$171.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$180.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.59
|
| Rate for Payer: University Health Alliance Commercial |
$231.09
|
|
|
54150 Circumcision w Regionl Block TechFee
|
Facility
|
IP
|
$4,757.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
8343983
|
|
Hospital Revenue Code
|
723
|
| Min. Negotiated Rate |
$4,043.45 |
| Max. Negotiated Rate |
$4,614.29 |
| Rate for Payer: Cash Price |
$3,092.05
|
| Rate for Payer: Health Management Network Commercial |
$4,043.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,281.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,614.29
|
|
|
54150 Circumcision w Regionl Block TechFee
|
Facility
|
OP
|
$4,757.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
8343983
|
|
Hospital Revenue Code
|
723
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,655.00 |
| Rate for Payer: AlohaCare Medicaid |
$672.48
|
| Rate for Payer: AlohaCare Medicare |
$2,378.50
|
| Rate for Payer: Cash Price |
$3,092.05
|
| Rate for Payer: Cash Price |
$3,092.05
|
| Rate for Payer: Devoted Health Medicare |
$2,616.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,655.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,378.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,519.15
|
| Rate for Payer: Health Management Network Commercial |
$4,043.45
|
| Rate for Payer: Humana Medicare |
$2,378.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,281.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,426.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,378.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,614.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,378.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,378.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,378.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
54161 Circumcision, surgical excision other than clamp or device; older than 28 days of age
|
Professional
|
Both
|
$2,909.00
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
8039776
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$183.18 |
| Max. Negotiated Rate |
$2,472.65 |
| Rate for Payer: AlohaCare Medicaid |
$202.13
|
| Rate for Payer: AlohaCare Medicare |
$183.18
|
| Rate for Payer: Cash Price |
$1,890.85
|
| Rate for Payer: Cash Price |
$1,890.85
|
| Rate for Payer: Devoted Health Medicare |
$201.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$183.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$206.18
|
| Rate for Payer: Health Management Network Commercial |
$2,472.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$201.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$201.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$202.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$183.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$202.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$183.18
|
|
|
54220-Irrigation Corpora Cavernosa
|
Facility
|
IP
|
$1,473.00
|
|
|
Service Code
|
HCPCS 54220
|
| Hospital Charge Code |
8080232
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,252.05 |
| Max. Negotiated Rate |
$1,428.81 |
| Rate for Payer: Cash Price |
$957.45
|
| Rate for Payer: Health Management Network Commercial |
$1,252.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,325.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,428.81
|
|
|
54220-Irrigation Corpora Cavernosa
|
Facility
|
OP
|
$1,473.00
|
|
|
Service Code
|
HCPCS 54220
|
| Hospital Charge Code |
8080232
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$525.09 |
| Max. Negotiated Rate |
$7,085.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$736.50
|
| Rate for Payer: Cash Price |
$957.45
|
| Rate for Payer: Cash Price |
$957.45
|
| Rate for Payer: Cash Price |
$957.45
|
| Rate for Payer: Devoted Health Medicare |
$810.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,085.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$736.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$849.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,399.35
|
| Rate for Payer: Health Management Network Commercial |
$1,252.05
|
| Rate for Payer: Humana Medicare |
$736.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,325.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$736.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,428.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$736.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$736.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$736.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
54235-Injection Corpora Cavernosa
|
Facility
|
IP
|
$1,186.00
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
8080235
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,008.10 |
| Max. Negotiated Rate |
$1,150.42 |
| Rate for Payer: Cash Price |
$770.90
|
| Rate for Payer: Health Management Network Commercial |
$1,008.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,067.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,150.42
|
|
|
54235-Injection Corpora Cavernosa
|
Facility
|
OP
|
$1,186.00
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
8080235
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$2,389.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$593.00
|
| Rate for Payer: Cash Price |
$770.90
|
| Rate for Payer: Cash Price |
$770.90
|
| Rate for Payer: Cash Price |
$770.90
|
| Rate for Payer: Devoted Health Medicare |
$652.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,389.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$593.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$407.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,126.70
|
| Rate for Payer: Health Management Network Commercial |
$1,008.10
|
| Rate for Payer: Humana Medicare |
$593.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,067.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$593.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,150.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$593.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$593.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$593.00
|
| Rate for Payer: University Health Alliance Commercial |
$864.48
|
|
|
54530 Orchiectomy, radical, for tumor; inguinal approach
|
Professional
|
Both
|
$4,983.00
|
|
|
Service Code
|
HCPCS 54530
|
| Hospital Charge Code |
8039800
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$475.14 |
| Max. Negotiated Rate |
$4,235.55 |
| Rate for Payer: AlohaCare Medicaid |
$522.09
|
| Rate for Payer: AlohaCare Medicare |
$475.14
|
| Rate for Payer: Cash Price |
$3,238.95
|
| Rate for Payer: Cash Price |
$3,238.95
|
| Rate for Payer: Devoted Health Medicare |
$522.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$475.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$596.70
|
| Rate for Payer: Health Management Network Commercial |
$4,235.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$522.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$522.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$522.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$522.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$475.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$522.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$475.14
|
| Rate for Payer: University Health Alliance Commercial |
$678.15
|
|
|
54700-I&D Epididymis/Testis/Scrotal Space
|
Facility
|
IP
|
$9,042.00
|
|
|
Service Code
|
HCPCS 54700
|
| Hospital Charge Code |
8080058
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$7,685.70 |
| Max. Negotiated Rate |
$8,770.74 |
| Rate for Payer: Cash Price |
$5,877.30
|
| Rate for Payer: Health Management Network Commercial |
$7,685.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,137.80
|
| Rate for Payer: MDX Hawaii PPO |
$8,770.74
|
|
