|
Urine Culture (Straight Cath) DLS
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 87086
|
| Hospital Charge Code |
27627630
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: AlohaCare Medicaid |
$65.00
|
| Rate for Payer: AlohaCare Medicare |
$54.60
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$119.60
|
| Rate for Payer: Devoted Health Medicare |
$54.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.07
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Humana Medicare |
$54.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.60
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.60
|
| Rate for Payer: University Health Alliance Commercial |
$20.87
|
|
|
Urine Culture (Straight Cath) DLS
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 87086
|
| Hospital Charge Code |
27627630
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
|
|
Urine Dipstick
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS 81003
|
| Hospital Charge Code |
422810030
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$17.64
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$38.64
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$3.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.25
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$17.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.64
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.64
|
| Rate for Payer: University Health Alliance Commercial |
$5.81
|
|
|
Urine Dipstick
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS 81003
|
| Hospital Charge Code |
422810030
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
Urine Microscopic 14
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 81015
|
| Hospital Charge Code |
422810150
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$28.98
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$63.48
|
| Rate for Payer: Devoted Health Medicare |
$28.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$4.20
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$3.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.05
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$28.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.98
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.98
|
| Rate for Payer: University Health Alliance Commercial |
$7.84
|
|
|
Urine Microscopic 14
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 81015
|
| Hospital Charge Code |
422810150
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$44.85
|
| 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
|
|
|
URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 81025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: AlohaCare Medicaid |
$8.74
|
| Rate for Payer: AlohaCare Medicare |
$8.61
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Devoted Health Medicare |
$8.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.75
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.61
|
|
|
Urine Protein ELP DLS
|
Facility
|
OP
|
$325.00
|
|
|
Service Code
|
HCPCS 84166
|
| Hospital Charge Code |
422841665
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.83 |
| Max. Negotiated Rate |
$315.25 |
| Rate for Payer: AlohaCare Medicaid |
$162.50
|
| Rate for Payer: AlohaCare Medicare |
$136.50
|
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$299.00
|
| Rate for Payer: Devoted Health Medicare |
$136.50
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$24.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$136.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.83
|
| Rate for Payer: Health Management Network Commercial |
$276.25
|
| Rate for Payer: Humana Medicare |
$136.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$292.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$165.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$136.50
|
| Rate for Payer: MDX Hawaii PPO |
$315.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$136.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$136.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$136.50
|
| Rate for Payer: University Health Alliance Commercial |
$46.10
|
|
|
Urine Protein ELP DLS
|
Facility
|
IP
|
$325.00
|
|
|
Service Code
|
HCPCS 84166
|
| Hospital Charge Code |
422841665
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$276.25 |
| Max. Negotiated Rate |
$315.25 |
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Health Management Network Commercial |
$276.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$292.50
|
| Rate for Payer: MDX Hawaii PPO |
$315.25
|
|
|
URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP
|
Professional
|
Both
|
$14.00
|
|
|
Service Code
|
HCPCS 81002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: AlohaCare Medicaid |
$3.54
|
| Rate for Payer: AlohaCare Medicare |
$3.48
|
| Rate for Payer: Cash Price |
$9.10
|
| Rate for Payer: Cash Price |
$9.10
|
| Rate for Payer: Devoted Health Medicare |
$3.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.55
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.48
|
|
|
ursodiol 250 mg Tab [KMC]
|
Facility
|
IP
|
$10.73
|
|
|
Service Code
|
NDC 64380091806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$10.41 |
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: Health Management Network Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.66
|
| Rate for Payer: MDX Hawaii PPO |
$10.41
|
|
|
ursodiol 250 mg Tab [KMC]
|
Facility
|
OP
|
$10.73
|
|
|
Service Code
|
NDC 64380091806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$10.41 |
| Rate for Payer: AlohaCare Medicaid |
$5.37
|
| Rate for Payer: AlohaCare Medicare |
$4.51
|
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$9.87
|
| Rate for Payer: Devoted Health Medicare |
$4.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.19
|
| Rate for Payer: Health Management Network Commercial |
$9.12
|
| Rate for Payer: Humana Medicare |
$4.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.51
|
| Rate for Payer: MDX Hawaii PPO |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.51
|
| Rate for Payer: University Health Alliance Commercial |
$7.82
|
|
|
ursodiol 300 mg Cap [KMC]
|
Facility
|
OP
|
$29.10
|
|
|
Service Code
|
NDC 72603061301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$28.23 |
| Rate for Payer: AlohaCare Medicaid |
$14.55
|
| Rate for Payer: AlohaCare Medicare |
$12.22
|
| Rate for Payer: Cash Price |
$18.92
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$26.77
|
| Rate for Payer: Devoted Health Medicare |
$12.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.64
|
| Rate for Payer: Health Management Network Commercial |
$24.73
|
| Rate for Payer: Humana Medicare |
$12.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.22
|
| Rate for Payer: MDX Hawaii PPO |
$28.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.22
|
| Rate for Payer: University Health Alliance Commercial |
$21.21
|
|
|
ursodiol 300 mg Cap [KMC]
|
Facility
|
IP
|
$29.10
|
|
|
Service Code
|
NDC 72603061301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.73 |
| Max. Negotiated Rate |
$28.23 |
| Rate for Payer: Cash Price |
$18.92
|
| Rate for Payer: Health Management Network Commercial |
$24.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$28.23
|
|
|
US ABDOMINAL
|
Facility
|
OP
|
$460.00
|
|
|
Service Code
|
HCPCS 76706
|
| Hospital Charge Code |
424767060
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$46.35 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: AlohaCare Medicaid |
$230.00
|
| Rate for Payer: AlohaCare Medicare |
$193.20
|
| Rate for Payer: Cash Price |
$299.00
|
| Rate for Payer: Cash Price |
$299.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$423.20
|
| Rate for Payer: Devoted Health Medicare |
$193.20
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$46.35
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$193.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$391.00
|
| Rate for Payer: Humana Medicare |
$193.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$414.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$234.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$193.20
|
| Rate for Payer: MDX Hawaii PPO |
$446.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$193.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$193.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$193.20
|
| Rate for Payer: University Health Alliance Commercial |
$196.82
|
|
|
US ABDOMINAL
|
Facility
|
IP
|
$460.00
|
|
|
Service Code
|
HCPCS 76706
|
| Hospital Charge Code |
424767060
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$391.00 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: Cash Price |
$299.00
|
| Rate for Payer: Health Management Network Commercial |
$391.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$414.00
|
| Rate for Payer: MDX Hawaii PPO |
$446.20
|
|
|
US ABDOMINAL LIMIT
|
Facility
|
OP
|
$689.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
424767050
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$668.33 |
| Rate for Payer: AlohaCare Medicaid |
$344.50
|
| Rate for Payer: AlohaCare Medicare |
$289.38
|
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$633.88
|
| Rate for Payer: Devoted Health Medicare |
$289.38
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$46.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$585.65
|
| Rate for Payer: Humana Medicare |
$289.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$620.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$351.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.38
|
| Rate for Payer: MDX Hawaii PPO |
$668.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.38
|
| Rate for Payer: University Health Alliance Commercial |
$200.93
|
|
|
US ABDOMINAL LIMIT
|
Facility
|
IP
|
$689.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
424767050
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$585.65 |
| Max. Negotiated Rate |
$668.33 |
| Rate for Payer: Cash Price |
$447.85
|
| Rate for Payer: Health Management Network Commercial |
$585.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$620.10
|
| Rate for Payer: MDX Hawaii PPO |
$668.33
|
|
|
US Bladder Only/ Post Void
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 51798
|
| Hospital Charge Code |
424517980
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: AlohaCare Medicaid |
$109.00
|
| Rate for Payer: AlohaCare Medicare |
$91.56
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$200.56
|
| Rate for Payer: Devoted Health Medicare |
$91.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.10
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Humana Medicare |
$91.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.56
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.56
|
| Rate for Payer: University Health Alliance Commercial |
$158.90
|
|
|
US Bladder Only/ Post Void
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 51798
|
| Hospital Charge Code |
424517980
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$185.30 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
|
|
US BLADDER SCAN ED Charge
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 51798
|
| Hospital Charge Code |
4501798
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$185.30 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
|
|
US BLADDER SCAN ED Charge
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 51798
|
| Hospital Charge Code |
4501798
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: AlohaCare Medicaid |
$109.00
|
| Rate for Payer: AlohaCare Medicare |
$91.56
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$200.56
|
| Rate for Payer: Devoted Health Medicare |
$91.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.10
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Humana Medicare |
$91.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.56
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.56
|
| Rate for Payer: University Health Alliance Commercial |
$158.90
|
|
|
US Breast Bilateral
|
Facility
|
IP
|
$462.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
424766420
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$392.70 |
| Max. Negotiated Rate |
$448.14 |
| Rate for Payer: Cash Price |
$300.30
|
| Rate for Payer: Health Management Network Commercial |
$392.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.80
|
| Rate for Payer: MDX Hawaii PPO |
$448.14
|
|
|
US Breast Bilateral
|
Facility
|
OP
|
$462.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
424766420
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$448.14 |
| Rate for Payer: AlohaCare Medicaid |
$231.00
|
| Rate for Payer: AlohaCare Medicare |
$194.04
|
| Rate for Payer: Cash Price |
$300.30
|
| Rate for Payer: Cash Price |
$300.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$425.04
|
| Rate for Payer: Devoted Health Medicare |
$194.04
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$392.70
|
| Rate for Payer: Humana Medicare |
$194.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$235.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.04
|
| Rate for Payer: MDX Hawaii PPO |
$448.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.04
|
| Rate for Payer: University Health Alliance Commercial |
$182.63
|
|
|
US Breast Left Complete
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
424766410
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$312.34 |
| Rate for Payer: AlohaCare Medicaid |
$161.00
|
| Rate for Payer: AlohaCare Medicare |
$135.24
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$296.24
|
| Rate for Payer: Devoted Health Medicare |
$135.24
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$34.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$135.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$273.70
|
| Rate for Payer: Humana Medicare |
$135.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$289.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$164.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$135.24
|
| Rate for Payer: MDX Hawaii PPO |
$312.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$135.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$135.24
|
| Rate for Payer: University Health Alliance Commercial |
$223.66
|
|
