|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687049501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904700061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
PR EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE
|
Professional
|
Both
|
$1,552.69
|
|
|
Service Code
|
HCPCS 43270
|
| Min. Negotiated Rate |
$198.73 |
| Max. Negotiated Rate |
$1,319.79 |
| Rate for Payer: AlohaCare Medicaid |
$223.73
|
| Rate for Payer: AlohaCare Medicare |
$198.73
|
| Rate for Payer: Cash Price |
$931.61
|
| Rate for Payer: Cash Price |
$931.61
|
| Rate for Payer: Devoted Health Medicare |
$218.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$223.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$386.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$198.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$223.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$818.74
|
| Rate for Payer: Health Management Network Commercial |
$1,319.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$238.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$238.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$223.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$198.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$223.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$198.73
|
| Rate for Payer: University Health Alliance Commercial |
$277.27
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Professional
|
Both
|
$2,320.06
|
|
|
Service Code
|
HCPCS 43249
|
| Min. Negotiated Rate |
$137.46 |
| Max. Negotiated Rate |
$1,972.05 |
| Rate for Payer: AlohaCare Medicaid |
$153.75
|
| Rate for Payer: AlohaCare Medicare |
$137.46
|
| Rate for Payer: Cash Price |
$1,392.04
|
| Rate for Payer: Cash Price |
$1,392.04
|
| Rate for Payer: Devoted Health Medicare |
$151.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$153.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$286.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$137.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$153.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$221.00
|
| Rate for Payer: Health Management Network Commercial |
$1,972.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$164.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$164.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$137.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$153.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$137.46
|
|
|
PR EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES
|
Professional
|
Both
|
$416.00
|
|
|
Service Code
|
HCPCS 43244
|
| Min. Negotiated Rate |
$216.56 |
| Max. Negotiated Rate |
$353.60 |
| Rate for Payer: AlohaCare Medicaid |
$244.34
|
| Rate for Payer: AlohaCare Medicare |
$216.56
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Devoted Health Medicare |
$238.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$216.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$295.88
|
| Rate for Payer: Health Management Network Commercial |
$353.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$259.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$259.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$244.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$216.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$244.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$216.56
|
|
|
PR EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
HCPCS 43257
|
| Min. Negotiated Rate |
$205.50 |
| Max. Negotiated Rate |
$335.75 |
| Rate for Payer: AlohaCare Medicaid |
$231.77
|
| Rate for Payer: AlohaCare Medicare |
$205.50
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Devoted Health Medicare |
$226.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$205.50
|
| Rate for Payer: Health Management Network Commercial |
$335.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$246.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$231.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$205.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$231.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$205.50
|
|
|
PR EGD DILATION GASTRIC/DUODENAL STRICTURE
|
Professional
|
Both
|
$1,266.21
|
|
|
Service Code
|
HCPCS 43245
|
| Min. Negotiated Rate |
$156.94 |
| Max. Negotiated Rate |
$1,076.28 |
| Rate for Payer: AlohaCare Medicaid |
$174.62
|
| Rate for Payer: AlohaCare Medicare |
$156.94
|
| Rate for Payer: Cash Price |
$759.73
|
| Rate for Payer: Cash Price |
$759.73
|
| Rate for Payer: Devoted Health Medicare |
$172.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$174.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$312.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.94
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$174.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$259.48
|
| Rate for Payer: Health Management Network Commercial |
$1,076.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$188.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$174.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.94
|
|
|
PR EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION
|
Professional
|
Both
|
$368.00
|
|
|
Service Code
|
HCPCS 43266
|
| Min. Negotiated Rate |
$192.32 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: AlohaCare Medicaid |
$215.93
|
| Rate for Payer: AlohaCare Medicare |
$192.32
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Devoted Health Medicare |
$211.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$192.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$231.40
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$230.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$230.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$230.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$192.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$215.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$192.32
|
|
|
PR EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER
|
Professional
|
Both
|
$386.00
|
|
|
Service Code
|
HCPCS 43233
|
| Min. Negotiated Rate |
$202.32 |
| Max. Negotiated Rate |
$328.10 |
| Rate for Payer: AlohaCare Medicaid |
$226.42
|
| Rate for Payer: AlohaCare Medicare |
$202.32
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Devoted Health Medicare |
$222.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$202.32
|
| Rate for Payer: Health Management Network Commercial |
$328.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$242.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$242.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$242.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$226.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$202.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$226.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$202.32
|
|
|
PR EGD FLEXIBLE FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$812.04
|
|
|
Service Code
|
HCPCS 43247
|
| Min. Negotiated Rate |
$157.92 |
| Max. Negotiated Rate |
$690.23 |
| Rate for Payer: AlohaCare Medicaid |
$176.40
|
| Rate for Payer: AlohaCare Medicare |
$157.92
|
| Rate for Payer: Cash Price |
$487.22
|
| Rate for Payer: Cash Price |
$487.22
|
| Rate for Payer: Devoted Health Medicare |
$173.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$176.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$331.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$157.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$176.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$258.96
|
| Rate for Payer: Health Management Network Commercial |
$690.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$189.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$189.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$176.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$157.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$176.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$157.92
|
|
|
PR EGD FLEX REMOVAL LESION(S) BY HOT BIOPSY FORCEPS
|
Professional
|
Both
|
$955.99
|
|
|
Service Code
|
HCPCS 43250
|
| Min. Negotiated Rate |
$152.46 |
| Max. Negotiated Rate |
$812.59 |
| Rate for Payer: AlohaCare Medicaid |
$169.24
|
| Rate for Payer: AlohaCare Medicare |
$152.46
|
| Rate for Payer: Cash Price |
$573.59
|
| Rate for Payer: Cash Price |
$573.59
|
| Rate for Payer: Devoted Health Medicare |
$167.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$169.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$313.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$169.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$246.48
|
| Rate for Payer: Health Management Network Commercial |
$812.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$182.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$182.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$152.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$169.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.46
|
|
|
PR EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS
|
Professional
|
Both
|
$877.33
|
|
|
Service Code
|
HCPCS 43248
|
| Min. Negotiated Rate |
$148.90 |
| Max. Negotiated Rate |
$745.73 |
| Rate for Payer: AlohaCare Medicaid |
$166.32
|
| Rate for Payer: AlohaCare Medicare |
$148.90
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: Devoted Health Medicare |
$163.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$166.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$309.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$166.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$240.76
|
| Rate for Payer: Health Management Network Commercial |
$745.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$178.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$178.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$166.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$166.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.90
|
|
|
PR EGD INTRALUMINAL TUBE/CATHETER INSERTION
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
HCPCS 43241
|
| Min. Negotiated Rate |
$127.60 |
| Max. Negotiated Rate |
$206.55 |
| Rate for Payer: AlohaCare Medicaid |
$142.21
|
| Rate for Payer: AlohaCare Medicare |
$127.60
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Devoted Health Medicare |
$140.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$200.46
|
| Rate for Payer: Health Management Network Commercial |
$206.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$142.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.60
|
|
|
PR EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY
|
Professional
|
Both
|
$723.00
|
|
|
Service Code
|
HCPCS 43210
|
| Min. Negotiated Rate |
$376.32 |
| Max. Negotiated Rate |
$614.55 |
| Rate for Payer: AlohaCare Medicaid |
$422.43
|
| Rate for Payer: AlohaCare Medicare |
$376.32
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Cash Price |
$433.80
|
| Rate for Payer: Devoted Health Medicare |
$413.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$376.32
|
| Rate for Payer: Health Management Network Commercial |
$614.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$451.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$451.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$451.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$422.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$376.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$422.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$376.32
|
|
|
PR EGD PERCUTANEOUS PLACEMENT GASTROSTOMY TUBE
|
Professional
|
Both
|
$338.00
|
|
|
Service Code
|
HCPCS 43246
|
| Min. Negotiated Rate |
$177.04 |
| Max. Negotiated Rate |
$330.72 |
| Rate for Payer: AlohaCare Medicaid |
$198.00
|
| Rate for Payer: AlohaCare Medicare |
$177.04
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Devoted Health Medicare |
$194.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$177.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$330.72
|
| Rate for Payer: Health Management Network Commercial |
$287.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$212.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$198.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$177.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$198.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$177.04
|
|
|
PR EGD REMOVAL TUMOR POLYP/OTHER LESION SNARE TECH
|
Professional
|
Both
|
$1,046.83
|
|
|
Service Code
|
HCPCS 43251
|
| Min. Negotiated Rate |
$173.98 |
| Max. Negotiated Rate |
$889.81 |
| Rate for Payer: AlohaCare Medicaid |
$195.64
|
| Rate for Payer: AlohaCare Medicare |
$173.98
|
| Rate for Payer: Cash Price |
$628.10
|
| Rate for Payer: Cash Price |
$628.10
|
| Rate for Payer: Devoted Health Medicare |
$191.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$195.64
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$360.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$173.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$195.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$215.54
|
| Rate for Payer: Health Management Network Commercial |
$889.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$208.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$208.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$208.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$195.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$173.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$195.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$173.98
|
|
|
PR EGD TRANSORAL BIOPSY SINGLE/MULTIPLE
|
Professional
|
Both
|
$805.94
|
|
|
Service Code
|
HCPCS 43239
|
| Min. Negotiated Rate |
$124.82 |
| Max. Negotiated Rate |
$685.05 |
| Rate for Payer: AlohaCare Medicaid |
$139.09
|
| Rate for Payer: AlohaCare Medicare |
$124.82
|
| Rate for Payer: Cash Price |
$483.56
|
| Rate for Payer: Cash Price |
$483.56
|
| Rate for Payer: Devoted Health Medicare |
$137.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$139.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$282.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$124.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$139.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.36
|
| Rate for Payer: Health Management Network Commercial |
$685.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$149.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$124.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$139.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$124.82
|
|
|
PR EGD TRANSORAL CONTROL BLEEDING ANY METHOD
|
Professional
|
Both
|
$1,331.21
|
|
|
Service Code
|
HCPCS 43255
|
| Min. Negotiated Rate |
$178.13 |
| Max. Negotiated Rate |
$1,131.53 |
| Rate for Payer: AlohaCare Medicaid |
$199.98
|
| Rate for Payer: AlohaCare Medicare |
$178.13
|
| Rate for Payer: Cash Price |
$798.73
|
| Rate for Payer: Cash Price |
$798.73
|
| Rate for Payer: Devoted Health Medicare |
$195.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$199.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$463.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$178.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$199.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$332.02
|
| Rate for Payer: Health Management Network Commercial |
$1,131.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$213.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$213.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$213.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$199.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$178.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$199.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$178.13
|
|
|
PR EGD TRANSORAL ENDOSCOPIC MUCOSAL RESECTION
|
Professional
|
Both
|
$459.00
|
|
|
Service Code
|
HCPCS 43254
|
| Min. Negotiated Rate |
$237.64 |
| Max. Negotiated Rate |
$390.15 |
| Rate for Payer: AlohaCare Medicaid |
$268.76
|
| Rate for Payer: AlohaCare Medicare |
$237.64
|
| Rate for Payer: Cash Price |
$275.40
|
| Rate for Payer: Cash Price |
$275.40
|
| Rate for Payer: Devoted Health Medicare |
$261.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$296.40
|
| Rate for Payer: Health Management Network Commercial |
$390.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$285.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$285.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$268.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$268.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
|
|
PR EKG FOR INITIAL PREVENT EXAM
|
Professional
|
Both
|
$28.56
|
|
|
Service Code
|
HCPCS G0403
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: AlohaCare Medicare |
$16.32
|
| Rate for Payer: Cash Price |
$17.14
|
| Rate for Payer: Cash Price |
$17.14
|
| Rate for Payer: Devoted Health Medicare |
$17.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.32
|
| Rate for Payer: Health Management Network Commercial |
$24.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.32
|
|
|
PR ELEC ALYS IMPLT CPLX CN NPGT PRGRMG
|
Professional
|
Both
|
$90.81
|
|
|
Service Code
|
HCPCS 95977
|
| Min. Negotiated Rate |
$42.39 |
| Max. Negotiated Rate |
$77.19 |
| Rate for Payer: AlohaCare Medicaid |
$51.75
|
| Rate for Payer: AlohaCare Medicare |
$42.39
|
| Rate for Payer: Cash Price |
$54.49
|
| Rate for Payer: Cash Price |
$54.49
|
| Rate for Payer: Devoted Health Medicare |
$46.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.75
|
| Rate for Payer: Health Management Network Commercial |
$77.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.39
|
|
|
PR ELEC ALYS IMPLT SMPL CN NPGT PRGRMG
|
Professional
|
Both
|
$68.13
|
|
|
Service Code
|
HCPCS 95976
|
| Min. Negotiated Rate |
$31.71 |
| Max. Negotiated Rate |
$57.91 |
| Rate for Payer: AlohaCare Medicaid |
$38.99
|
| Rate for Payer: AlohaCare Medicare |
$31.71
|
| Rate for Payer: Cash Price |
$40.88
|
| Rate for Payer: Cash Price |
$40.88
|
| Rate for Payer: Devoted Health Medicare |
$34.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$38.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$57.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.71
|
|
|
PR ELECTROCONVULSIVE THERAPY
|
Professional
|
Both
|
$339.26
|
|
|
Service Code
|
HCPCS 90870
|
| Min. Negotiated Rate |
$98.91 |
| Max. Negotiated Rate |
$288.37 |
| Rate for Payer: AlohaCare Medicaid |
$104.97
|
| Rate for Payer: AlohaCare Medicare |
$98.91
|
| Rate for Payer: Cash Price |
$203.56
|
| Rate for Payer: Cash Price |
$203.56
|
| Rate for Payer: Devoted Health Medicare |
$108.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.97
|
| Rate for Payer: Health Management Network Commercial |
$288.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$118.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.91
|
| Rate for Payer: University Health Alliance Commercial |
$127.21
|
|
|
PR ELECTROCORTICOGRAM SURGERY SPX
|
Professional
|
Both
|
$5,882.00
|
|
|
Service Code
|
HCPCS 95829
|
| Min. Negotiated Rate |
$192.25 |
| Max. Negotiated Rate |
$4,999.70 |
| Rate for Payer: AlohaCare Medicaid |
$1,990.80
|
| Rate for Payer: AlohaCare Medicare |
$2,208.16
|
| Rate for Payer: Cash Price |
$3,529.20
|
| Rate for Payer: Cash Price |
$3,529.20
|
| Rate for Payer: Devoted Health Medicare |
$2,428.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,208.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$192.25
|
| Rate for Payer: Health Management Network Commercial |
$4,999.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,649.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,649.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,649.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,990.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,208.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,990.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,208.16
|
|
|
PR ELECTROCORTICOGRAM SURGERY SPX
|
Professional
|
Both
|
$5,270.00
|
|
|
Service Code
|
HCPCS 95829 TC
|
| Min. Negotiated Rate |
$192.25 |
| Max. Negotiated Rate |
$4,479.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,990.80
|
| Rate for Payer: AlohaCare Medicare |
$1,858.43
|
| Rate for Payer: Cash Price |
$3,162.00
|
| Rate for Payer: Cash Price |
$3,162.00
|
| Rate for Payer: Devoted Health Medicare |
$2,044.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,858.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$192.25
|
| Rate for Payer: Health Management Network Commercial |
$4,479.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,230.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,230.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,230.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,990.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,858.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,990.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,858.43
|
|
