|
clopidogrel 300 mg Tab [KMC]
|
Facility
|
OP
|
$63.77
|
|
|
Service Code
|
NDC 63739017830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$61.86 |
| Rate for Payer: AlohaCare Medicaid |
$31.89
|
| Rate for Payer: AlohaCare Medicare |
$26.78
|
| Rate for Payer: Cash Price |
$41.45
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$58.67
|
| Rate for Payer: Devoted Health Medicare |
$26.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.58
|
| Rate for Payer: Health Management Network Commercial |
$54.20
|
| Rate for Payer: Humana Medicare |
$26.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.78
|
| Rate for Payer: MDX Hawaii PPO |
$61.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.78
|
| Rate for Payer: University Health Alliance Commercial |
$46.48
|
|
|
clopidogrel 75 mg Tab [KMC]
|
Facility
|
OP
|
$19.80
|
|
|
Service Code
|
NDC 16714005211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: AlohaCare Medicaid |
$9.90
|
| Rate for Payer: AlohaCare Medicare |
$8.32
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$18.22
|
| Rate for Payer: Devoted Health Medicare |
$8.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.81
|
| Rate for Payer: Health Management Network Commercial |
$16.83
|
| Rate for Payer: Humana Medicare |
$8.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.32
|
| Rate for Payer: MDX Hawaii PPO |
$19.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.32
|
| Rate for Payer: University Health Alliance Commercial |
$14.43
|
|
|
clopidogrel 75 mg Tab [KMC]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
NDC 16714005211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Health Management Network Commercial |
$16.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.82
|
| Rate for Payer: MDX Hawaii PPO |
$19.21
|
|
|
CLOSED REDUCTION, FINGER CHARGE
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 26770
|
| Hospital Charge Code |
440267700
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
CLOSED REDUCTION, FINGER CHARGE
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 26770
|
| Hospital Charge Code |
440267700
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT, KNEECAP DISL CHARGE
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 27560
|
| Hospital Charge Code |
440275600
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT, KNEECAP DISL CHARGE
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 27560
|
| Hospital Charge Code |
440275600
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
CLOSED TREATMENT OF ACETABULUM FRACTURE WITHOUT MA
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 27220
|
| Hospital Charge Code |
440272200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT OF ACETABULUM FRACTURE WITHOUT MA
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 27220
|
| Hospital Charge Code |
440272200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING M
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 26740
|
| Hospital Charge Code |
440267400
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| 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 |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
CLOSED TREATMENT OF ARTICULAR FRACTURE INVOLVING M
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 26740
|
| Hospital Charge Code |
440267400
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
CLOSED TREATMENT OF CARPAL BONE FRACTURE OTHER THA
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 25635
|
| Hospital Charge Code |
440256350
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
CLOSED TREATMENT OF CARPAL BONE FRACTURE OTHER THA
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 25635
|
| Hospital Charge Code |
440256350
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| 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 |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLO
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 26645
|
| Hospital Charge Code |
440266450
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| 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 |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLO
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 26645
|
| Hospital Charge Code |
440266450
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIP
|
Facility
|
IP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 23505
|
| Hospital Charge Code |
440235050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,949.90 |
| Max. Negotiated Rate |
$2,225.18 |
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Health Management Network Commercial |
$1,949.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,064.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,225.18
|
|
|
CLOSED TREATMENT OF CLAVICULAR FRACTURE WITH MANIP
|
Facility
|
OP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 23505
|
| Hospital Charge Code |
440235050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,225.18 |
| Rate for Payer: AlohaCare Medicaid |
$1,147.00
|
| Rate for Payer: AlohaCare Medicare |
$963.48
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2,110.48
|
| Rate for Payer: Devoted Health Medicare |
$963.48
|
| 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 |
$963.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,179.30
|
| Rate for Payer: Health Management Network Commercial |
$1,949.90
|
| Rate for Payer: Humana Medicare |
$963.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,064.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$963.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,225.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$963.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$963.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$963.48
|
| Rate for Payer: University Health Alliance Commercial |
$1,672.10
|
|
|
CLOSED TREATMENT OF COCCYGEAL FRACTURE CHARGE
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 27200
|
| Hospital Charge Code |
440272000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT OF COCCYGEAL FRACTURE CHARGE
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 27200
|
| Hospital Charge Code |
440272000
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPA
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 27517
|
| Hospital Charge Code |
440275170
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPA
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 27517
|
| Hospital Charge Code |
440275170
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| 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 |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPA
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 27516
|
| Hospital Charge Code |
440275160
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPA
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 27516
|
| Hospital Charge Code |
440275160
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FIN
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 26750
|
| Hospital Charge Code |
440267500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| 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 |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE FIN
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 26750
|
| Hospital Charge Code |
440267500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
