|
Initial Observation Care Level 1 - 99218
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
HCPCS 99218
|
| Hospital Charge Code |
400992180
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$72.12 |
| Max. Negotiated Rate |
$255.85 |
| Rate for Payer: Cash Price |
$195.65
|
| Rate for Payer: Cash Price |
$195.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.12
|
| Rate for Payer: Health Management Network Commercial |
$255.85
|
|
|
Initial Observation Care Level 2 - 99219
|
Professional
|
Both
|
$409.00
|
|
|
Service Code
|
HCPCS 99219
|
| Hospital Charge Code |
400992190
|
|
Hospital Revenue Code
|
987
|
| Min. Negotiated Rate |
$115.81 |
| Max. Negotiated Rate |
$347.65 |
| Rate for Payer: Cash Price |
$265.85
|
| Rate for Payer: Cash Price |
$265.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$115.81
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS G0402
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$114.81 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicare |
$114.81
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Devoted Health Medicare |
$114.81
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT <1YEAR
|
Professional
|
Both
|
$283.00
|
|
|
Service Code
|
HCPCS 99381
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$53.86 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$73.80
|
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Cash Price |
$183.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.86
|
| Rate for Payer: Health Management Network Commercial |
$240.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS 99386
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$64.63 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$114.60
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.63
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS&>
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS 99387
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$86.17 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$123.12
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Cash Price |
$75.40
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.17
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$123.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 12-17 YR
|
Professional
|
Both
|
$273.00
|
|
|
Service Code
|
HCPCS 99384
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$75.41 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$98.65
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Cash Price |
$177.45
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.41
|
| Rate for Payer: Health Management Network Commercial |
$232.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 1-4 YRS
|
Professional
|
Both
|
$299.00
|
|
|
Service Code
|
HCPCS 99382
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$62.67 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$78.84
|
| Rate for Payer: Cash Price |
$194.35
|
| Rate for Payer: Cash Price |
$194.35
|
| Rate for Payer: Cash Price |
$194.35
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.67
|
| Rate for Payer: Health Management Network Commercial |
$254.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
HCPCS 99385
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$64.63 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$94.46
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.63
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS
|
Professional
|
Both
|
$317.00
|
|
|
Service Code
|
HCPCS 99383
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$67.77 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$83.70
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.77
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
INITIAL TX 1ST DEG BURN ED Charge
|
Facility
|
IP
|
$311.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
440160000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$264.35 |
| Max. Negotiated Rate |
$301.67 |
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Health Management Network Commercial |
$264.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.90
|
| Rate for Payer: MDX Hawaii PPO |
$301.67
|
|
|
INITIAL TX 1ST DEG BURN ED Charge
|
Facility
|
OP
|
$311.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
440160000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$130.62 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$155.50
|
| Rate for Payer: AlohaCare Medicare |
$130.62
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$286.12
|
| Rate for Payer: Devoted Health Medicare |
$130.62
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$130.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$295.45
|
| Rate for Payer: Health Management Network Commercial |
$264.35
|
| Rate for Payer: Humana Medicare |
$130.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$130.62
|
| Rate for Payer: MDX Hawaii PPO |
$301.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$130.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$130.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$130.62
|
| Rate for Payer: University Health Alliance Commercial |
$226.69
|
|
|
INJ ANESTH; FACIAL NER Charge
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
HCPCS 64402
|
| Hospital Charge Code |
440644020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$487.91 |
| Rate for Payer: Cash Price |
$326.95
|
| Rate for Payer: Health Management Network Commercial |
$427.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$452.70
|
| Rate for Payer: MDX Hawaii PPO |
$487.91
|
|
|
INJ ANESTH; FACIAL NER Charge
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
HCPCS 64402
|
| Hospital Charge Code |
440644020
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$211.26 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$251.50
|
| Rate for Payer: AlohaCare Medicare |
$211.26
|
| Rate for Payer: Cash Price |
$326.95
|
| Rate for Payer: Cash Price |
$326.95
|
| Rate for Payer: Cash Price |
$326.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$462.76
|
| Rate for Payer: Devoted Health Medicare |
$211.26
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$211.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$477.85
|
| Rate for Payer: Health Management Network Commercial |
$427.55
|
| Rate for Payer: Humana Medicare |
$211.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$452.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$211.26
|
| Rate for Payer: MDX Hawaii PPO |
$487.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$211.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$211.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$211.26
|
| Rate for Payer: University Health Alliance Commercial |
$366.64
|
|
|
INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Professional
|
Both
|
$917.00
|
|
|
Service Code
|
HCPCS 20550
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$32.96 |
| Max. Negotiated Rate |
$779.45 |
| Rate for Payer: AlohaCare Medicaid |
$38.69
|
| Rate for Payer: AlohaCare Medicare |
$32.96
|
| Rate for Payer: Cash Price |
$596.05
|
| Rate for Payer: Cash Price |
$596.05
|
| Rate for Payer: Devoted Health Medicare |
$32.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$38.69
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.58
|
| Rate for Payer: Health Management Network Commercial |
$779.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.96
|
| Rate for Payer: University Health Alliance Commercial |
$48.22
|
|
|
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NERVE
|
Facility
|
OP
|
$1,809.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
440644050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,754.73 |
| Rate for Payer: AlohaCare Medicaid |
$904.50
|
| Rate for Payer: AlohaCare Medicare |
$759.78
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,664.28
|
| Rate for Payer: Devoted Health Medicare |
$759.78
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$759.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,718.55
|
| Rate for Payer: Health Management Network Commercial |
$1,537.65
|
| Rate for Payer: Humana Medicare |
$759.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,628.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$759.78
|
| Rate for Payer: MDX Hawaii PPO |
$1,754.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$759.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$759.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$759.78
|
| Rate for Payer: University Health Alliance Commercial |
$1,318.58
|
|
|
INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NERVE
|
Facility
|
IP
|
$1,809.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
440644050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,537.65 |
| Max. Negotiated Rate |
$1,754.73 |
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Health Management Network Commercial |
$1,537.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,628.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,754.73
|
|
|
INJECTION ANESTHETIC AGENT OTHER PERIPHERAL NERVE
|
Facility
|
OP
|
$1,809.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
440644500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$904.50
|
| Rate for Payer: AlohaCare Medicare |
$759.78
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,664.28
|
| Rate for Payer: Devoted Health Medicare |
$759.78
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$759.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,718.55
|
| Rate for Payer: Health Management Network Commercial |
$1,537.65
|
| Rate for Payer: Humana Medicare |
$759.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,628.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$759.78
|
| Rate for Payer: MDX Hawaii PPO |
$1,754.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$759.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$759.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$759.78
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
INJECTION ANESTHETIC AGENT OTHER PERIPHERAL NERVE
|
Facility
|
IP
|
$1,809.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
440644500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,537.65 |
| Max. Negotiated Rate |
$1,754.73 |
| Rate for Payer: Cash Price |
$1,175.85
|
| Rate for Payer: Health Management Network Commercial |
$1,537.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,628.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,754.73
|
|
|
INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS 20552
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$138.55 |
| Rate for Payer: AlohaCare Medicaid |
$37.23
|
| Rate for Payer: AlohaCare Medicare |
$36.40
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Devoted Health Medicare |
$36.40
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$37.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.80
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.40
|
| Rate for Payer: University Health Alliance Commercial |
$45.72
|
|
|
INJECTION SINGLE TENDON ORIGIN/INSERTION
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 20551
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$32.77 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$32.77
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Devoted Health Medicare |
$32.77
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$38.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.80
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.77
|
| Rate for Payer: University Health Alliance Commercial |
$47.75
|
|
|
INJ SGL TENDON SHTH OR LIGAMEN Charge
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
440205500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$517.50
|
| Rate for Payer: AlohaCare Medicare |
$434.70
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$952.20
|
| Rate for Payer: Devoted Health Medicare |
$434.70
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$434.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$983.25
|
| Rate for Payer: Health Management Network Commercial |
$879.75
|
| Rate for Payer: Humana Medicare |
$434.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$931.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$434.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,003.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$434.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$434.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$434.70
|
| Rate for Payer: University Health Alliance Commercial |
$754.41
|
|
|
INJ SGL TENDON SHTH OR LIGAMEN Charge
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
440205500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$879.75 |
| Max. Negotiated Rate |
$1,003.95 |
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Health Management Network Commercial |
$879.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$931.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,003.95
|
|
|
INJ SING/MULT TRIG PT 3 MUSCLE Charge
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
440205530
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$517.50
|
| Rate for Payer: AlohaCare Medicare |
$434.70
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$952.20
|
| Rate for Payer: Devoted Health Medicare |
$434.70
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$434.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$983.25
|
| Rate for Payer: Health Management Network Commercial |
$879.75
|
| Rate for Payer: Humana Medicare |
$434.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$931.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$434.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,003.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$434.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$434.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$434.70
|
| Rate for Payer: University Health Alliance Commercial |
$754.41
|
|
|
INJ SING/MULT TRIG PT 3 MUSCLE Charge
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
440205530
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$879.75 |
| Max. Negotiated Rate |
$1,003.95 |
| Rate for Payer: Cash Price |
$672.75
|
| Rate for Payer: Health Management Network Commercial |
$879.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$931.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,003.95
|
|
