|
57200 COLPORRHAPHY SUTURE INJURY VAGINA TechFee
|
Facility
|
IP
|
$9,886.00
|
|
|
Service Code
|
HCPCS 57200
|
| Hospital Charge Code |
8218188
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$8,403.10 |
| Max. Negotiated Rate |
$9,589.42 |
| Rate for Payer: Cash Price |
$6,425.90
|
| Rate for Payer: Health Management Network Commercial |
$8,403.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,897.40
|
| Rate for Payer: MDX Hawaii PPO |
$9,589.42
|
|
|
57200 Colporrhaphy, suture of injury of vagina (nonobstetrical)
|
Professional
|
Both
|
$4,505.00
|
|
|
Service Code
|
HCPCS 57200
|
| Hospital Charge Code |
8039868
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$264.94 |
| Max. Negotiated Rate |
$3,829.25 |
| Rate for Payer: AlohaCare Medicaid |
$349.51
|
| Rate for Payer: AlohaCare Medicare |
$311.72
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Devoted Health Medicare |
$342.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$311.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$264.94
|
| Rate for Payer: Health Management Network Commercial |
$3,829.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$342.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$349.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$311.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$349.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$311.72
|
|
|
57285 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED); VAGINAL APPRO ProFee
|
Professional
|
Both
|
$10,320.00
|
|
|
Service Code
|
HCPCS 57285
|
| Hospital Charge Code |
8020996
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$611.99 |
| Max. Negotiated Rate |
$8,772.00 |
| Rate for Payer: AlohaCare Medicaid |
$705.06
|
| Rate for Payer: AlohaCare Medicare |
$611.99
|
| Rate for Payer: Cash Price |
$6,708.00
|
| Rate for Payer: Cash Price |
$6,708.00
|
| Rate for Payer: Devoted Health Medicare |
$673.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$611.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$647.40
|
| Rate for Payer: Health Management Network Commercial |
$8,772.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$673.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$673.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$673.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$705.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$611.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$705.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$611.99
|
|
|
57410 Pelvic examination under anesthesia (other than local)
|
Professional
|
Both
|
$303.00
|
|
|
Service Code
|
HCPCS 57410
|
| Hospital Charge Code |
8039887
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.58 |
| Max. Negotiated Rate |
$257.55 |
| Rate for Payer: AlohaCare Medicaid |
$107.65
|
| Rate for Payer: AlohaCare Medicare |
$96.34
|
| Rate for Payer: Cash Price |
$196.95
|
| Rate for Payer: Cash Price |
$196.95
|
| Rate for Payer: Devoted Health Medicare |
$105.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.58
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$105.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.34
|
|
|
57421 Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix
|
Professional
|
Both
|
$448.00
|
|
|
Service Code
|
HCPCS 57421
|
| Hospital Charge Code |
8039890
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$106.52 |
| Max. Negotiated Rate |
$380.80 |
| Rate for Payer: AlohaCare Medicaid |
$121.25
|
| Rate for Payer: AlohaCare Medicare |
$106.52
|
| Rate for Payer: Cash Price |
$291.20
|
| Rate for Payer: Cash Price |
$291.20
|
| Rate for Payer: Devoted Health Medicare |
$117.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$121.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$202.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$121.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.34
|
| Rate for Payer: Health Management Network Commercial |
$380.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$117.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$121.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.52
|
| Rate for Payer: University Health Alliance Commercial |
$159.78
|
|
|
57452 Colposcopy of the cervix including upper/adjacent vagina
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
HCPCS 57452
|
| Hospital Charge Code |
8039892
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$345.10 |
| Rate for Payer: AlohaCare Medicaid |
$92.28
|
| Rate for Payer: AlohaCare Medicare |
$82.28
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Devoted Health Medicare |
$90.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$92.28
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$152.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$92.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.58
|
| Rate for Payer: Health Management Network Commercial |
$345.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$90.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$92.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.28
|
| Rate for Payer: University Health Alliance Commercial |
$114.35
|
|
|
57454 Colposcopy of the cervix incl. vagina w/ biopsy of cervix and endocervical curettage
|
Professional
|
Both
|
$582.00
|
|
|
Service Code
|
HCPCS 57454
|
| Hospital Charge Code |
8039893
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$104.78 |
| Max. Negotiated Rate |
$494.70 |
| Rate for Payer: AlohaCare Medicaid |
$134.18
|
| Rate for Payer: AlohaCare Medicare |
$117.36
|
| Rate for Payer: Cash Price |
$378.30
|
| Rate for Payer: Cash Price |
$378.30
|
| Rate for Payer: Devoted Health Medicare |
$129.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$134.18
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$224.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$134.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$104.78
|
| Rate for Payer: Health Management Network Commercial |
$494.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$129.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$129.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$134.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$134.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.36
|
| Rate for Payer: University Health Alliance Commercial |
$166.07
|
|
|
57455 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 57455
|
| Hospital Charge Code |
8039894
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$94.17 |
| Max. Negotiated Rate |
$454.75 |
| Rate for Payer: AlohaCare Medicaid |
$107.97
|
| Rate for Payer: AlohaCare Medicare |
$94.17
|
| Rate for Payer: Cash Price |
$347.75
|
| Rate for Payer: Cash Price |
$347.75
|
| Rate for Payer: Devoted Health Medicare |
$103.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$107.97
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$181.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$107.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.02
|
| Rate for Payer: Health Management Network Commercial |
$454.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.17
|
| Rate for Payer: University Health Alliance Commercial |
$133.96
|
|
|
57456 Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
|
Professional
|
Both
|
$506.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
8039895
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$87.01 |
| Max. Negotiated Rate |
$430.10 |
| Rate for Payer: AlohaCare Medicaid |
$100.65
|
| Rate for Payer: AlohaCare Medicare |
$87.01
|
| Rate for Payer: Cash Price |
$328.90
|
| Rate for Payer: Cash Price |
$328.90
|
| Rate for Payer: Devoted Health Medicare |
$95.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$100.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$168.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$100.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.74
|
| Rate for Payer: Health Management Network Commercial |
$430.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.01
|
| Rate for Payer: University Health Alliance Commercial |
$123.75
|
|
|
57460 Colposcopy of the cervix incl. upper vagina; with loop electrode biopsy(s) of the cervix
|
Professional
|
Both
|
$4,505.00
|
|
|
Service Code
|
HCPCS 57460
|
| Hospital Charge Code |
8039896
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$139.45 |
| Max. Negotiated Rate |
$3,829.25 |
| Rate for Payer: AlohaCare Medicaid |
$159.59
|
| Rate for Payer: AlohaCare Medicare |
$139.45
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Devoted Health Medicare |
$153.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$159.59
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$266.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$159.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.88
|
| Rate for Payer: Health Management Network Commercial |
$3,829.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$159.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$159.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.45
|
| Rate for Payer: University Health Alliance Commercial |
$197.88
|
|
|
57500 Biopsy of cervix, single or multiple, or local excision of lesion, w/ or w/o fulguration
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
HCPCS 57500
|
| Hospital Charge Code |
8039898
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$431.80 |
| Rate for Payer: AlohaCare Medicaid |
$76.57
|
| Rate for Payer: AlohaCare Medicare |
$68.58
|
| Rate for Payer: Cash Price |
$330.20
|
| Rate for Payer: Cash Price |
$330.20
|
| Rate for Payer: Devoted Health Medicare |
$75.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$76.57
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$126.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$76.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.34
|
| Rate for Payer: Health Management Network Commercial |
$431.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$76.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.58
|
| Rate for Payer: University Health Alliance Commercial |
$94.97
|
|
|
57510 Cautery of cervix; electro or thermal
|
Professional
|
Both
|
$4,505.00
|
|
|
Service Code
|
HCPCS 57510
|
| Hospital Charge Code |
8039900
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$3,829.25 |
| Rate for Payer: AlohaCare Medicaid |
$114.74
|
| Rate for Payer: AlohaCare Medicare |
$101.41
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Devoted Health Medicare |
$111.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$114.74
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$190.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$101.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$114.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.50
|
| Rate for Payer: Health Management Network Commercial |
$3,829.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$101.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$101.41
|
| Rate for Payer: University Health Alliance Commercial |
$149.80
|
|
|
57511 Cautery of cervix; cryocautery, initial or repeat
|
Professional
|
Both
|
$419.00
|
|
|
Service Code
|
HCPCS 57511
|
| Hospital Charge Code |
8039901
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$118.04 |
| Max. Negotiated Rate |
$356.15 |
| Rate for Payer: AlohaCare Medicaid |
$154.83
|
| Rate for Payer: AlohaCare Medicare |
$134.60
|
| Rate for Payer: Cash Price |
$272.35
|
| Rate for Payer: Cash Price |
$272.35
|
| Rate for Payer: Devoted Health Medicare |
$148.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$154.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$134.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$154.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.04
|
| Rate for Payer: Health Management Network Commercial |
$356.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$148.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$148.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$134.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$154.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$134.60
|
| Rate for Payer: University Health Alliance Commercial |
$203.05
|
|
|
57520 Conization of cervix; cold knife or laser
|
Professional
|
Both
|
$4,505.00
|
|
|
Service Code
|
HCPCS 57520
|
| Hospital Charge Code |
8039903
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$277.96 |
| Max. Negotiated Rate |
$3,829.25 |
| Rate for Payer: AlohaCare Medicaid |
$310.14
|
| Rate for Payer: AlohaCare Medicare |
$277.96
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Devoted Health Medicare |
$305.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$310.14
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$514.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$277.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$310.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$305.50
|
| Rate for Payer: Health Management Network Commercial |
$3,829.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$305.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$305.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$277.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$310.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$277.96
|
| Rate for Payer: University Health Alliance Commercial |
$382.51
|
|
|
58100 Endometrial biopsy with or w/o endocer biopsy, w/o cervical dilation, any method
|
Professional
|
Both
|
$379.00
|
|
|
Service Code
|
HCPCS 58100
|
| Hospital Charge Code |
8039911
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$53.35 |
| Max. Negotiated Rate |
$322.15 |
| Rate for Payer: AlohaCare Medicaid |
$62.37
|
| Rate for Payer: AlohaCare Medicare |
$53.35
|
| Rate for Payer: Cash Price |
$246.35
|
| Rate for Payer: Cash Price |
$246.35
|
| Rate for Payer: Devoted Health Medicare |
$58.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$62.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$62.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.30
|
| Rate for Payer: Health Management Network Commercial |
$322.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$62.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.35
|
| Rate for Payer: University Health Alliance Commercial |
$76.97
|
|
|
58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)
|
Professional
|
Both
|
$4,505.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
8039913
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$210.36 |
| Max. Negotiated Rate |
$3,829.25 |
| Rate for Payer: AlohaCare Medicaid |
$240.48
|
| Rate for Payer: AlohaCare Medicare |
$210.36
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Cash Price |
$2,928.25
|
| Rate for Payer: Devoted Health Medicare |
$231.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$240.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$402.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$210.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$240.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$247.00
|
| Rate for Payer: Health Management Network Commercial |
$3,829.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$231.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$231.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$240.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$210.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$240.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$210.36
|
| Rate for Payer: University Health Alliance Commercial |
$316.81
|
|
|
58140 Myomectomy, excision, 1-4 intramural myoma(s), weight of 250 g or less; abdominal approach
|
Professional
|
Both
|
$2,558.00
|
|
|
Service Code
|
HCPCS 58140
|
| Hospital Charge Code |
8039914
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$803.56 |
| Max. Negotiated Rate |
$2,174.30 |
| Rate for Payer: AlohaCare Medicaid |
$931.74
|
| Rate for Payer: AlohaCare Medicare |
$803.56
|
| Rate for Payer: Cash Price |
$1,662.70
|
| Rate for Payer: Cash Price |
$1,662.70
|
| Rate for Payer: Devoted Health Medicare |
$883.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$803.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$875.42
|
| Rate for Payer: Health Management Network Commercial |
$2,174.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$883.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$883.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$931.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$803.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$931.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$803.56
|
|
|
58146 Myomectomy, excision of fibroid tumor(s) of uterus, 5+ myomas; abdominal approach
|
Professional
|
Both
|
$3,167.00
|
|
|
Service Code
|
HCPCS 58146
|
| Hospital Charge Code |
8039916
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$977.86 |
| Max. Negotiated Rate |
$2,691.95 |
| Rate for Payer: AlohaCare Medicaid |
$1,160.68
|
| Rate for Payer: AlohaCare Medicare |
$998.32
|
| Rate for Payer: Cash Price |
$2,058.55
|
| Rate for Payer: Cash Price |
$2,058.55
|
| Rate for Payer: Devoted Health Medicare |
$1,098.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$998.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$977.86
|
| Rate for Payer: Health Management Network Commercial |
$2,691.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,098.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,098.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,160.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$998.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,160.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$998.32
|
|
|
58150 Total abdominal hysterectomy, with or w/o removal of tube(s), with or w/o removal of ovary(s)
|
Professional
|
Both
|
$2,884.00
|
|
|
Service Code
|
HCPCS 58150
|
| Hospital Charge Code |
8039917
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$920.28 |
| Max. Negotiated Rate |
$2,451.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,028.32
|
| Rate for Payer: AlohaCare Medicare |
$920.28
|
| Rate for Payer: Cash Price |
$1,874.60
|
| Rate for Payer: Cash Price |
$1,874.60
|
| Rate for Payer: Devoted Health Medicare |
$1,012.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$920.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$951.60
|
| Rate for Payer: Health Management Network Commercial |
$2,451.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,012.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,012.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,012.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,028.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$920.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,028.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$920.28
|
|
|
58180 Supracervical abdominal hysterectomy
|
Professional
|
Both
|
$2,666.00
|
|
|
Service Code
|
HCPCS 58180
|
| Hospital Charge Code |
8039919
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$568.36 |
| Max. Negotiated Rate |
$2,266.10 |
| Rate for Payer: AlohaCare Medicaid |
$970.11
|
| Rate for Payer: AlohaCare Medicare |
$854.94
|
| Rate for Payer: Cash Price |
$1,732.90
|
| Rate for Payer: Cash Price |
$1,732.90
|
| Rate for Payer: Devoted Health Medicare |
$940.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$854.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$568.36
|
| Rate for Payer: Health Management Network Commercial |
$2,266.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$940.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$940.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$940.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$970.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$854.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$970.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$854.94
|
|
|
58300 Insertion of intrauterine device (IUD)
|
Professional
|
Both
|
$354.00
|
|
|
Service Code
|
HCPCS 58300
|
| Hospital Charge Code |
8039933
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$300.90 |
| Rate for Payer: AlohaCare Medicaid |
$50.40
|
| Rate for Payer: Cash Price |
$230.10
|
| Rate for Payer: Cash Price |
$230.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$96.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.02
|
| Rate for Payer: Health Management Network Commercial |
$300.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
|
|
58301-Intrauterine Device
|
Facility
|
OP
|
$1,124.00
|
|
|
Service Code
|
HCPCS 58301
|
| Hospital Charge Code |
8080136
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$562.00
|
| Rate for Payer: Cash Price |
$730.60
|
| Rate for Payer: Cash Price |
$730.60
|
| Rate for Payer: Cash Price |
$730.60
|
| Rate for Payer: Devoted Health Medicare |
$618.20
|
| 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 |
$562.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,067.80
|
| Rate for Payer: Health Management Network Commercial |
$955.40
|
| Rate for Payer: Humana Medicare |
$562.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,011.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$562.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,090.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$562.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$562.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$562.00
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
58301-Intrauterine Device
|
Facility
|
IP
|
$1,124.00
|
|
|
Service Code
|
HCPCS 58301
|
| Hospital Charge Code |
8080136
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$955.40 |
| Max. Negotiated Rate |
$1,090.28 |
| Rate for Payer: Cash Price |
$730.60
|
| Rate for Payer: Health Management Network Commercial |
$955.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,011.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,090.28
|
|
|
58301 Removal of intrauterine device (IUD)
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
HCPCS 58301
|
| Hospital Charge Code |
8039934
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$56.11 |
| Max. Negotiated Rate |
$306.00 |
| Rate for Payer: AlohaCare Medicaid |
$65.32
|
| Rate for Payer: AlohaCare Medicare |
$56.11
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Devoted Health Medicare |
$61.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$65.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$110.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$65.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.14
|
| Rate for Payer: Health Management Network Commercial |
$306.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.11
|
| Rate for Payer: University Health Alliance Commercial |
$80.61
|
|
|
58350 Chromotubation of oviduct, including materials
|
Professional
|
Both
|
$6,962.00
|
|
|
Service Code
|
HCPCS 58350
|
| Hospital Charge Code |
8039938
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$5,917.70 |
| Rate for Payer: AlohaCare Medicaid |
$101.37
|
| Rate for Payer: AlohaCare Medicare |
$87.25
|
| Rate for Payer: Cash Price |
$4,525.30
|
| Rate for Payer: Cash Price |
$4,525.30
|
| Rate for Payer: Devoted Health Medicare |
$95.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$101.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$151.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.25
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$101.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.50
|
| Rate for Payer: Health Management Network Commercial |
$5,917.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$101.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.25
|
| Rate for Payer: University Health Alliance Commercial |
$133.77
|
|
