|
HARTMANN FORCEPS STRAIGHT 3.5"
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
8551
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1.84
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.84
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.84
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
HAVRIX Hepatitis A Vaccine [KMC]
|
Facility
|
OP
|
$350.40
|
|
|
Service Code
|
NDC 58160082611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.17 |
| Max. Negotiated Rate |
$339.89 |
| Rate for Payer: AlohaCare Medicaid |
$175.20
|
| Rate for Payer: AlohaCare Medicare |
$147.17
|
| Rate for Payer: Cash Price |
$227.76
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$322.37
|
| Rate for Payer: Devoted Health Medicare |
$147.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$332.88
|
| Rate for Payer: Health Management Network Commercial |
$297.84
|
| Rate for Payer: Humana Medicare |
$147.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$178.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.17
|
| Rate for Payer: MDX Hawaii PPO |
$339.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$147.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$210.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.17
|
| Rate for Payer: University Health Alliance Commercial |
$255.41
|
|
|
HAVRIX Hepatitis A Vaccine [KMC]
|
Facility
|
IP
|
$350.40
|
|
|
Service Code
|
NDC 58160082611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$297.84 |
| Max. Negotiated Rate |
$339.89 |
| Rate for Payer: Cash Price |
$227.76
|
| Rate for Payer: Health Management Network Commercial |
$297.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.36
|
| Rate for Payer: MDX Hawaii PPO |
$339.89
|
|
|
Hawaii Regional Resp Allergy Profile DLS
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
422860036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$314.50 |
| Max. Negotiated Rate |
$358.90 |
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Health Management Network Commercial |
$314.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.00
|
| Rate for Payer: MDX Hawaii PPO |
$358.90
|
|
|
Hawaii Regional Resp Allergy Profile DLS
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
422860036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$358.90 |
| Rate for Payer: AlohaCare Medicaid |
$185.00
|
| Rate for Payer: AlohaCare Medicare |
$155.40
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$340.40
|
| Rate for Payer: Devoted Health Medicare |
$155.40
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$7.22
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.22
|
| Rate for Payer: Health Management Network Commercial |
$314.50
|
| Rate for Payer: Humana Medicare |
$155.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.40
|
| Rate for Payer: MDX Hawaii PPO |
$358.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.40
|
| Rate for Payer: University Health Alliance Commercial |
$13.51
|
|
|
HB VARIANT BY MASS SPEC, B DLS
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
422837895
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$611.10 |
| Rate for Payer: AlohaCare Medicaid |
$315.00
|
| Rate for Payer: AlohaCare Medicare |
$264.60
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$579.60
|
| Rate for Payer: Devoted Health Medicare |
$264.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$24.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$30.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$264.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.11
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Humana Medicare |
$264.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$321.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$264.60
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$264.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$264.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$264.60
|
| Rate for Payer: University Health Alliance Commercial |
$46.68
|
|
|
HB VARIANT BY MASS SPEC, B DLS
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
422837895
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$611.10 |
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
|
|
HC APPL MLT-LAYER VENOUS WOUND COMPRESS BELOW KNEE
|
Professional
|
Both
|
$474.00
|
|
|
Service Code
|
HCPCS 29581
|
| Hospital Charge Code |
761295810
|
| Min. Negotiated Rate |
$23.32 |
| Max. Negotiated Rate |
$402.90 |
| Rate for Payer: AlohaCare Medicaid |
$27.04
|
| Rate for Payer: AlohaCare Medicare |
$23.32
|
| Rate for Payer: Cash Price |
$308.10
|
| Rate for Payer: Cash Price |
$308.10
|
| Rate for Payer: Devoted Health Medicare |
$23.32
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$27.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.80
|
| Rate for Payer: Health Management Network Commercial |
$402.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.32
|
| Rate for Payer: University Health Alliance Commercial |
$36.27
|
|
|
HC CHEM CAUTERY GRANULATN TISSUE
|
Professional
|
Both
|
$597.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
761172500
|
| Min. Negotiated Rate |
$34.84 |
| Max. Negotiated Rate |
$507.45 |
| Rate for Payer: AlohaCare Medicaid |
$39.17
|
| Rate for Payer: AlohaCare Medicare |
$36.71
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Devoted Health Medicare |
$36.71
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$39.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.84
|
| Rate for Payer: Health Management Network Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.71
|
|
|
HC DEBRIDEMENT OF NAIL(S), 1-5
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 11720
|
| Hospital Charge Code |
761117200
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$152.15 |
| Rate for Payer: AlohaCare Medicaid |
$13.89
|
| Rate for Payer: AlohaCare Medicare |
$12.45
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$12.45
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.74
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.45
|
| Rate for Payer: University Health Alliance Commercial |
$15.40
|
|
|
HC DEBRIDEMENT OF NAILS, 6 OR MORE
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 11721
|
| Hospital Charge Code |
761117210
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$152.15 |
| Rate for Payer: AlohaCare Medicaid |
$23.31
|
| Rate for Payer: AlohaCare Medicare |
$20.95
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$20.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$23.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.12
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.95
|
| Rate for Payer: University Health Alliance Commercial |
$25.55
|
|
|
HC DEBRIDEMENT OPEN WOUND 20 SQ CM<
|
Professional
|
Both
|
$597.00
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
761975970
|
| Min. Negotiated Rate |
$30.95 |
| Max. Negotiated Rate |
$507.45 |
| Rate for Payer: AlohaCare Medicaid |
$35.17
|
| Rate for Payer: AlohaCare Medicare |
$30.95
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Devoted Health Medicare |
$30.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$35.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$58.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.88
|
| Rate for Payer: Health Management Network Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.95
|
| Rate for Payer: University Health Alliance Commercial |
$145.00
|
|
|
HC DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM
|
Professional
|
Both
|
$383.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
761975980
|
| Min. Negotiated Rate |
$21.32 |
| Max. Negotiated Rate |
$325.55 |
| Rate for Payer: AlohaCare Medicaid |
$24.27
|
| Rate for Payer: AlohaCare Medicare |
$21.32
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Devoted Health Medicare |
$21.32
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$24.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$72.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.18
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.32
|
|
|
HC DRAINAGE OF HEMATOMA/FLUID
|
Professional
|
Both
|
$3,241.00
|
|
|
Service Code
|
HCPCS 10140
|
| Hospital Charge Code |
761101400
|
| Min. Negotiated Rate |
$47.58 |
| Max. Negotiated Rate |
$2,754.85 |
| Rate for Payer: AlohaCare Medicaid |
$124.60
|
| Rate for Payer: AlohaCare Medicare |
$120.44
|
| Rate for Payer: Cash Price |
$2,106.65
|
| Rate for Payer: Cash Price |
$2,106.65
|
| Rate for Payer: Devoted Health Medicare |
$120.44
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$124.60
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$189.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.58
|
| Rate for Payer: Health Management Network Commercial |
$2,754.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$124.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$124.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.44
|
| Rate for Payer: University Health Alliance Commercial |
$140.50
|
|
|
HC DRESS/DEBRID SMALL BURN NO ANES
|
Professional
|
Both
|
$597.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761160200
|
| Min. Negotiated Rate |
$47.58 |
| Max. Negotiated Rate |
$507.45 |
| Rate for Payer: AlohaCare Medicaid |
$58.39
|
| Rate for Payer: AlohaCare Medicare |
$56.51
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Cash Price |
$388.05
|
| Rate for Payer: Devoted Health Medicare |
$56.51
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$58.39
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.58
|
| Rate for Payer: Health Management Network Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.51
|
| Rate for Payer: University Health Alliance Commercial |
$100.00
|
|
|
hCG Qualitative
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
hCG Qualitative
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: AlohaCare Medicaid |
$69.00
|
| Rate for Payer: AlohaCare Medicare |
$57.96
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$126.96
|
| Rate for Payer: Devoted Health Medicare |
$57.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$10.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.52
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Humana Medicare |
$57.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.96
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.96
|
| Rate for Payer: University Health Alliance Commercial |
$19.41
|
|
|
hCG Qualitative, Serum 3
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: AlohaCare Medicaid |
$69.00
|
| Rate for Payer: AlohaCare Medicare |
$57.96
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$126.96
|
| Rate for Payer: Devoted Health Medicare |
$57.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$10.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.52
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Humana Medicare |
$57.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.96
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.96
|
| Rate for Payer: University Health Alliance Commercial |
$19.41
|
|
|
hCG Qualitative, Serum 3
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
hCG Quantitative
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
422847020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$251.23 |
| Rate for Payer: AlohaCare Medicaid |
$129.50
|
| Rate for Payer: AlohaCare Medicare |
$108.78
|
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$238.28
|
| Rate for Payer: Devoted Health Medicare |
$108.78
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$20.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.05
|
| Rate for Payer: Health Management Network Commercial |
$220.15
|
| Rate for Payer: Humana Medicare |
$108.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$233.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$132.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.78
|
| Rate for Payer: MDX Hawaii PPO |
$251.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.78
|
| Rate for Payer: University Health Alliance Commercial |
$38.91
|
|
|
hCG Quantitative
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
422847020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$220.15 |
| Max. Negotiated Rate |
$251.23 |
| Rate for Payer: Cash Price |
$168.35
|
| Rate for Payer: Health Management Network Commercial |
$220.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$233.10
|
| Rate for Payer: MDX Hawaii PPO |
$251.23
|
|
|
HCG, Quantitative, Pregnancy DLS
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
422847025Â
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$34.44
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$75.44
|
| Rate for Payer: Devoted Health Medicare |
$34.44
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$20.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.05
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Humana Medicare |
$34.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.44
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.44
|
| Rate for Payer: University Health Alliance Commercial |
$38.91
|
|
|
HCG, Quantitative, Pregnancy DLS
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
422847025Â
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
hCG Urine Qualitative
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: AlohaCare Medicaid |
$69.00
|
| Rate for Payer: AlohaCare Medicare |
$57.96
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$126.96
|
| Rate for Payer: Devoted Health Medicare |
$57.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$10.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.52
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Humana Medicare |
$57.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.96
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.96
|
| Rate for Payer: University Health Alliance Commercial |
$19.41
|
|
|
hCG Urine Qualitative
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 84703
|
| Hospital Charge Code |
422847030
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
