|
HC KEPPRA/LEVETRACETAM (WKEPPA)
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
3018017701
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
|
|
HC KETONE BODIES SERUM QUANTITATIVE - BETA HYDROXYBUTYRATE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
3018201002
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
|
|
HC KETONE BODIES SERUM QUANTITATIVE - BETA HYDROXYBUTYRATE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
3018201002
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$52.44
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Devoted Health Medicare |
$57.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.17
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$52.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.44
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.44
|
| Rate for Payer: University Health Alliance Commercial |
$21.13
|
|
|
HC LACOSAMIDE
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 80235
|
| Hospital Charge Code |
3018023501
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.27 |
| Max. Negotiated Rate |
$220.19 |
| Rate for Payer: AlohaCare Medicaid |
$113.50
|
| Rate for Payer: AlohaCare Medicare |
$172.52
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Devoted Health Medicare |
$190.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.21
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$33.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.11
|
| Rate for Payer: Health Management Network Commercial |
$192.95
|
| Rate for Payer: Humana Medicare |
$172.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$204.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.52
|
| Rate for Payer: MDX Hawaii PPO |
$220.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.52
|
| Rate for Payer: University Health Alliance Commercial |
$165.46
|
|
|
HC LACOSAMIDE
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 80235
|
| Hospital Charge Code |
3018023501
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$192.95 |
| Max. Negotiated Rate |
$220.19 |
| Rate for Payer: Cash Price |
$136.20
|
| Rate for Payer: Health Management Network Commercial |
$192.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$204.30
|
| Rate for Payer: MDX Hawaii PPO |
$220.19
|
|
|
HC LAMOTRIGINE SO (LAMOT)
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
HCPCS 80175
|
| Hospital Charge Code |
3018017501
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: AlohaCare Medicaid |
$55.50
|
| Rate for Payer: AlohaCare Medicare |
$84.36
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Devoted Health Medicare |
$93.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.11
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.25
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Humana Medicare |
$84.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.36
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.36
|
| Rate for Payer: University Health Alliance Commercial |
$33.47
|
|
|
HC LAMOTRIGINE SO (LAMOT)
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
HCPCS 80175
|
| Hospital Charge Code |
3018017501
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
|
|
HC LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL
|
Facility
|
OP
|
$6,863.00
|
|
|
Service Code
|
HCPCS 31530
|
| Hospital Charge Code |
4503153001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$6,657.11 |
| Rate for Payer: AlohaCare Medicaid |
$3,431.50
|
| Rate for Payer: AlohaCare Medicare |
$5,215.88
|
| Rate for Payer: Cash Price |
$4,117.80
|
| Rate for Payer: Cash Price |
$4,117.80
|
| Rate for Payer: Devoted Health Medicare |
$5,764.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,215.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,519.85
|
| Rate for Payer: Health Management Network Commercial |
$5,833.55
|
| Rate for Payer: Humana Medicare |
$5,215.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,176.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,215.88
|
| Rate for Payer: MDX Hawaii PPO |
$6,657.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,215.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,215.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,215.88
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
HC LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL
|
Facility
|
IP
|
$6,863.00
|
|
|
Service Code
|
HCPCS 31530
|
| Hospital Charge Code |
4503153001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,833.55 |
| Max. Negotiated Rate |
$6,657.11 |
| Rate for Payer: Cash Price |
$4,117.80
|
| Rate for Payer: Health Management Network Commercial |
$5,833.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,176.70
|
| Rate for Payer: MDX Hawaii PPO |
$6,657.11
|
|
|
HC LARYNGOSCOPY, DIRECT, WITH FOREIGN BODY REMOVAL; CHILD UNDER 5 YEARS
|
Facility
|
IP
|
$756.00
|
|
|
Service Code
|
HCPCS 31511
|
| Hospital Charge Code |
4503151101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$642.60 |
| Max. Negotiated Rate |
$733.32 |
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Health Management Network Commercial |
$642.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$680.40
|
| Rate for Payer: MDX Hawaii PPO |
$733.32
|
|
|
HC LARYNGOSCOPY, DIRECT, WITH FOREIGN BODY REMOVAL; CHILD UNDER 5 YEARS
|
Facility
|
OP
|
$756.00
|
|
|
Service Code
|
HCPCS 31511
|
| Hospital Charge Code |
4503151101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$378.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$378.00
|
| Rate for Payer: AlohaCare Medicare |
$574.56
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Devoted Health Medicare |
$635.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$574.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$718.20
|
| Rate for Payer: Health Management Network Commercial |
$642.60
|
| Rate for Payer: Humana Medicare |
$574.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$680.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$574.56
|
| Rate for Payer: MDX Hawaii PPO |
$733.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$574.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$574.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$574.56
|
| Rate for Payer: University Health Alliance Commercial |
$551.05
|
|
|
HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$1,545.00
|
|
|
Service Code
|
HCPCS 31577
|
| Hospital Charge Code |
4503157701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$772.50
|
| Rate for Payer: AlohaCare Medicare |
$1,174.20
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Devoted Health Medicare |
$1,297.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,174.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,467.75
|
| Rate for Payer: Health Management Network Commercial |
$1,313.25
|
| Rate for Payer: Humana Medicare |
$1,174.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,390.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,174.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,498.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,174.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,174.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,174.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,126.15
|
|
|
HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY
|
Facility
|
IP
|
$1,545.00
|
|
|
Service Code
|
HCPCS 31577
|
| Hospital Charge Code |
4503157701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,313.25 |
| Max. Negotiated Rate |
$1,498.65 |
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Health Management Network Commercial |
$1,313.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,390.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,498.65
|
|
|
HC LAYR CLOS WND FACE,FACIAL 12.6-20 CM
|
Facility
|
OP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
7611205501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$795.00
|
| Rate for Payer: AlohaCare Medicare |
$1,208.40
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Devoted Health Medicare |
$1,335.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,208.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,510.50
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Humana Medicare |
$1,208.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,208.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,208.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,208.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,158.95
|
|
|
HC LAYR CLOS WND FACE,FACIAL 12.6-20 CM
|
Facility
|
IP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
7611205501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,351.50 |
| Max. Negotiated Rate |
$1,542.30 |
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
|
|
HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM
|
Facility
|
IP
|
$1,557.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
3611205601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,323.45 |
| Max. Negotiated Rate |
$1,510.29 |
| Rate for Payer: Cash Price |
$934.20
|
| Rate for Payer: Health Management Network Commercial |
$1,323.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,401.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,510.29
|
|
|
HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM
|
Facility
|
OP
|
$1,557.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
3611205601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$778.50
|
| Rate for Payer: AlohaCare Medicare |
$1,183.32
|
| Rate for Payer: Cash Price |
$934.20
|
| Rate for Payer: Cash Price |
$934.20
|
| Rate for Payer: Devoted Health Medicare |
$1,307.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,183.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,479.15
|
| Rate for Payer: Health Management Network Commercial |
$1,323.45
|
| Rate for Payer: Humana Medicare |
$1,183.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,401.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,183.32
|
| Rate for Payer: MDX Hawaii PPO |
$1,510.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,183.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,183.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,183.32
|
| Rate for Payer: University Health Alliance Commercial |
$1,134.90
|
|
|
HC LAYR CLOS WND FACE,FACIAL 2.5-5 CM
|
Facility
|
IP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
4501205201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,351.50 |
| Max. Negotiated Rate |
$1,542.30 |
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
|
|
HC LAYR CLOS WND FACE,FACIAL 2.5-5 CM
|
Facility
|
OP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
4501205201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$795.00
|
| Rate for Payer: AlohaCare Medicare |
$1,208.40
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Devoted Health Medicare |
$1,335.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,208.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,510.50
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Humana Medicare |
$1,208.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,208.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,208.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,208.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,158.95
|
|
|
HC LAYR CLOS WND FACE,FACIAL >30 CM
|
Facility
|
IP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
3611205701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,351.50 |
| Max. Negotiated Rate |
$1,542.30 |
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
|
|
HC LAYR CLOS WND FACE,FACIAL >30 CM
|
Facility
|
OP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
3611205701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$795.00
|
| Rate for Payer: AlohaCare Medicare |
$1,208.40
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Devoted Health Medicare |
$1,335.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,208.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,510.50
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Humana Medicare |
$1,208.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,208.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,208.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,208.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,158.95
|
|
|
HC LAYR CLOS WND REST BODY <2.5 CM
|
Facility
|
OP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
4501204101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$795.00
|
| Rate for Payer: AlohaCare Medicare |
$1,208.40
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Devoted Health Medicare |
$1,335.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,208.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,510.50
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Humana Medicare |
$1,208.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,208.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,208.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,208.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,158.95
|
|
|
HC LAYR CLOS WND REST BODY <2.5 CM
|
Facility
|
IP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
4501204101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,351.50 |
| Max. Negotiated Rate |
$1,542.30 |
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
|
|
HC LAYR CLOS WND REST BODY 2.6-7.5 CM
|
Facility
|
OP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
4501204201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$795.00
|
| Rate for Payer: AlohaCare Medicare |
$1,208.40
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Devoted Health Medicare |
$1,335.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,208.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,510.50
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Humana Medicare |
$1,208.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,208.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,208.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,208.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,158.95
|
|
|
HC LAYR CLOS WND REST BODY 2.6-7.5 CM
|
Facility
|
IP
|
$1,590.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
4501204201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,351.50 |
| Max. Negotiated Rate |
$1,542.30 |
| Rate for Payer: Cash Price |
$954.00
|
| Rate for Payer: Health Management Network Commercial |
$1,351.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,542.30
|
|
