|
warfarin 7.5 mg Tab [KMC]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 00093172301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: AlohaCare Medicaid |
$1.96
|
| Rate for Payer: AlohaCare Medicare |
$1.65
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3.61
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.72
|
| Rate for Payer: Health Management Network Commercial |
$3.33
|
| Rate for Payer: Humana Medicare |
$1.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.65
|
| Rate for Payer: MDX Hawaii PPO |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.65
|
| Rate for Payer: University Health Alliance Commercial |
$2.86
|
|
|
WATER SEAL CHEST DRAIN
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
8484
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$7.98
|
| Rate for Payer: Cash Price |
$12.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$17.48
|
| Rate for Payer: Devoted Health Medicare |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$7.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.98
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.98
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
WATER SEAL CHEST DRAIN
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
8484
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
WBC - Stool DLS
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 85048
|
| Hospital Charge Code |
422850485
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
WBC - Stool DLS
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 85048
|
| Hospital Charge Code |
422850485
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: AlohaCare Medicaid |
$33.50
|
| Rate for Payer: AlohaCare Medicare |
$28.14
|
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$61.64
|
| Rate for Payer: Devoted Health Medicare |
$28.14
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$3.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$3.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.54
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Humana Medicare |
$28.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.14
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.14
|
| Rate for Payer: University Health Alliance Commercial |
$6.57
|
|
|
WEDGE EXCISION SKIN NAIL FOLD
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
HCPCS 11765
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$260.95 |
| Rate for Payer: AlohaCare Medicaid |
$99.08
|
| Rate for Payer: AlohaCare Medicare |
$94.28
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Devoted Health Medicare |
$94.28
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$99.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.18
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$113.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$99.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.28
|
| Rate for Payer: University Health Alliance Commercial |
$107.70
|
|
|
WEIGHT RECORDED
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 2001F
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 |
$0.01
|
| 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: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
Wet Prep 6
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
422872100
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
Wet Prep 6
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
422872100
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicare |
$20.16
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$44.16
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$5.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.82
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$20.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.16
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.16
|
| Rate for Payer: University Health Alliance Commercial |
$11.03
|
|
|
Wheelchair Charge
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
426975420
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
Wheelchair Charge
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
426975420
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
Wheelchair Management Charges
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GP
|
| Hospital Charge Code |
432975420
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
Wheelchair Management Charges
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GP
|
| Hospital Charge Code |
432975420
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
WHEELCHAIR MGMT EA 15 MIN
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
HCPCS 97542
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$137.70 |
| Rate for Payer: AlohaCare Medicaid |
$33.76
|
| Rate for Payer: AlohaCare Medicare |
$32.94
|
| Rate for Payer: Cash Price |
$105.30
|
| Rate for Payer: Cash Price |
$105.30
|
| Rate for Payer: Devoted Health Medicare |
$32.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.76
|
| Rate for Payer: Health Management Network Commercial |
$137.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.94
|
|
|
WHEELCHAIR MGMT EA 15 MIN Occupational
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
426975420
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
WHEELCHAIR MGMT EA 15 MIN Occupational
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
426975420
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
WHEELCHAIR MGMT EA 15 MIN Physical
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GP
|
| Hospital Charge Code |
432975420
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
WHEELCHAIR MGMT EA 15 MIN Physical
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97542 GP
|
| Hospital Charge Code |
432975420
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
WHFO CF F-ARM T-SPICA Occupational
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
HCPCS L3806
|
| Hospital Charge Code |
432L38060
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$30.49 |
| Max. Negotiated Rate |
$599.46 |
| Rate for Payer: AlohaCare Medicaid |
$309.00
|
| Rate for Payer: AlohaCare Medicare |
$259.56
|
| Rate for Payer: Cash Price |
$401.70
|
| Rate for Payer: Cash Price |
$401.70
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$568.56
|
| Rate for Payer: Devoted Health Medicare |
$259.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$259.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$432.60
|
| Rate for Payer: Health Management Network Commercial |
$525.30
|
| Rate for Payer: Humana Medicare |
$259.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$259.56
|
| Rate for Payer: MDX Hawaii PPO |
$599.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$259.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$259.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$259.56
|
| Rate for Payer: University Health Alliance Commercial |
$346.08
|
|
|
WHFO CF F-ARM T-SPICA Occupational
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
HCPCS L3806
|
| Hospital Charge Code |
432L38060
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$346.08 |
| Max. Negotiated Rate |
$599.46 |
| Rate for Payer: Cash Price |
$401.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$432.60
|
| Rate for Payer: Health Management Network Commercial |
$525.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.20
|
| Rate for Payer: MDX Hawaii PPO |
$599.46
|
| Rate for Payer: University Health Alliance Commercial |
$346.08
|
|
|
WHFO CFW/O JOINTS Occupational
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS L3808
|
| Hospital Charge Code |
432L38080
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$18.94 |
| Max. Negotiated Rate |
$762.42 |
| Rate for Payer: AlohaCare Medicaid |
$393.00
|
| Rate for Payer: AlohaCare Medicare |
$330.12
|
| Rate for Payer: Cash Price |
$510.90
|
| Rate for Payer: Cash Price |
$510.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$723.12
|
| Rate for Payer: Devoted Health Medicare |
$330.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$330.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$550.20
|
| Rate for Payer: Health Management Network Commercial |
$668.10
|
| Rate for Payer: Humana Medicare |
$330.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$707.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$400.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$330.12
|
| Rate for Payer: MDX Hawaii PPO |
$762.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$330.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$330.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$330.12
|
| Rate for Payer: University Health Alliance Commercial |
$440.16
|
|
|
WHFO CFW/O JOINTS Occupational
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS L3808
|
| Hospital Charge Code |
432L38080
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$440.16 |
| Max. Negotiated Rate |
$762.42 |
| Rate for Payer: Cash Price |
$510.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$550.20
|
| Rate for Payer: Health Management Network Commercial |
$668.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$707.40
|
| Rate for Payer: MDX Hawaii PPO |
$762.42
|
| Rate for Payer: University Health Alliance Commercial |
$440.16
|
|
|
WHFO PF (EG NEO/ LYCRA) Occupational
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS L3911
|
| Hospital Charge Code |
432L39110
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$105.80
|
| Rate for Payer: Devoted Health Medicare |
$48.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$80.50
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$64.40
|
|
|
WHFO PF (EG NEO/ LYCRA) Occupational
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS L3911
|
| Hospital Charge Code |
432L39110
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$64.40 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$80.50
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: University Health Alliance Commercial |
$64.40
|
|
|
WHFO PFGAUNT W/DRSL HD Occupational
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS L3931
|
| Hospital Charge Code |
432L39310
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$195.44 |
| Max. Negotiated Rate |
$338.53 |
| Rate for Payer: Cash Price |
$226.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.30
|
| Rate for Payer: Health Management Network Commercial |
$296.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$314.10
|
| Rate for Payer: MDX Hawaii PPO |
$338.53
|
| Rate for Payer: University Health Alliance Commercial |
$195.44
|
|
