|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687047311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00071101268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00071101268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687047301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687047311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687048401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904699261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904699261
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
PREGABALIN 50 MG CAPSULE [42163]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687048401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687049501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687049501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687049511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687049511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 75 MG CAPSULE [42164]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904700061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| 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 |
$359.53
|
| 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 |
$266.91
|
| 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 |
$290.64
|
| 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 |
$308.20
|
| 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 |
$292.02
|
| 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 |
$288.06
|
| 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
|
|
