|
HC INJ,ANES AGENT,BRACHIAL PLEXUS,SINGLE
|
Facility
|
IP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
3616441501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,011.55 |
| Max. Negotiated Rate |
$3,436.71 |
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
|
|
HC INJ,ANES AGENT,FEMORAL NERVE,SINGLE
|
Facility
|
OP
|
$2,756.00
|
|
|
Service Code
|
HCPCS 64447
|
| Hospital Charge Code |
3706444701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,378.00
|
| Rate for Payer: AlohaCare Medicare |
$854.36
|
| Rate for Payer: Cash Price |
$1,653.60
|
| Rate for Payer: Cash Price |
$1,653.60
|
| Rate for Payer: Devoted Health Medicare |
$937.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$854.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,618.20
|
| Rate for Payer: Health Management Network Commercial |
$2,342.60
|
| Rate for Payer: Humana Medicare |
$854.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,480.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$854.36
|
| Rate for Payer: MDX Hawaii PPO |
$2,673.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$854.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$854.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$854.36
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC INJ,ANES AGENT,FEMORAL NERVE,SINGLE
|
Facility
|
IP
|
$2,756.00
|
|
|
Service Code
|
HCPCS 64447
|
| Hospital Charge Code |
3706444701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,342.60 |
| Max. Negotiated Rate |
$2,673.32 |
| Rate for Payer: Cash Price |
$1,653.60
|
| Rate for Payer: Health Management Network Commercial |
$2,342.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,480.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,673.32
|
|
|
HC INJ,ANES AGENT,SCIATIC NERVE,SINGLE
|
Facility
|
IP
|
$2,699.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
3706444501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,294.15 |
| Max. Negotiated Rate |
$2,618.03 |
| Rate for Payer: Cash Price |
$1,619.40
|
| Rate for Payer: Health Management Network Commercial |
$2,294.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,429.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,618.03
|
|
|
HC INJ,ANES AGENT,SCIATIC NERVE,SINGLE
|
Facility
|
OP
|
$2,699.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
3706444501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,618.03 |
| Rate for Payer: AlohaCare Medicaid |
$1,349.50
|
| Rate for Payer: AlohaCare Medicare |
$836.69
|
| Rate for Payer: Cash Price |
$1,619.40
|
| Rate for Payer: Cash Price |
$1,619.40
|
| Rate for Payer: Devoted Health Medicare |
$917.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$836.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,564.05
|
| Rate for Payer: Health Management Network Commercial |
$2,294.15
|
| Rate for Payer: Humana Medicare |
$836.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,429.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$836.69
|
| Rate for Payer: MDX Hawaii PPO |
$2,618.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$836.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$836.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$836.69
|
| Rate for Payer: University Health Alliance Commercial |
$1,967.30
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL
|
Facility
|
OP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
3616449001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,771.50
|
| Rate for Payer: AlohaCare Medicare |
$1,098.33
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Devoted Health Medicare |
$1,204.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,365.85
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Humana Medicare |
$1,098.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.33
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,098.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.33
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,CERV/THORAC, 1ST LEVEL
|
Facility
|
IP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
3616449001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,011.55 |
| Max. Negotiated Rate |
$3,436.71 |
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL
|
Facility
|
OP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
3616449301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,771.50
|
| Rate for Payer: AlohaCare Medicare |
$1,098.33
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Devoted Health Medicare |
$1,204.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,365.85
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Humana Medicare |
$1,098.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.33
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,098.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.33
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC INJ DX/THER AGNT PARAVERT FACET JOINT,IMG GUIDE,LUMBAR/SAC, 1ST LEVEL
|
Facility
|
IP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
3616449301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,011.55 |
| Max. Negotiated Rate |
$3,436.71 |
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
|
|
HC INJECT ANES/STEROID FORAMEN CERV/THORACIC W IMG GUIDE ,1 LEVEL
|
Facility
|
IP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
3616447901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,011.55 |
| Max. Negotiated Rate |
$3,436.71 |
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
|
|
HC INJECT ANES/STEROID FORAMEN CERV/THORACIC W IMG GUIDE ,1 LEVEL
|
Facility
|
OP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
3616447901
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,771.50
|
| Rate for Payer: AlohaCare Medicare |
$1,098.33
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Devoted Health Medicare |
$1,204.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,365.85
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Humana Medicare |
$1,098.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.33
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,098.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.33
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL
|
Facility
|
IP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
3616448301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,011.55 |
| Max. Negotiated Rate |
$3,436.71 |
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
|
|
HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL
|
Facility
|
OP
|
$3,543.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
3616448301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,771.50
|
| Rate for Payer: AlohaCare Medicare |
$1,098.33
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Cash Price |
$2,125.80
|
| Rate for Payer: Devoted Health Medicare |
$1,204.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,365.85
|
| Rate for Payer: Health Management Network Commercial |
$3,011.55
|
| Rate for Payer: Humana Medicare |
$1,098.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,188.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.33
|
| Rate for Payer: MDX Hawaii PPO |
$3,436.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,098.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.33
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; VAGUS NERVE
|
Facility
|
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS 64408
|
| Hospital Charge Code |
4506440801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$356.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$575.00
|
| Rate for Payer: AlohaCare Medicare |
$356.50
|
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Devoted Health Medicare |
$391.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,092.50
|
| Rate for Payer: Health Management Network Commercial |
$977.50
|
| Rate for Payer: Humana Medicare |
$356.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,035.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,115.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.50
|
| Rate for Payer: University Health Alliance Commercial |
$838.24
|
|
|
HC INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; VAGUS NERVE
|
Facility
|
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS 64408
|
| Hospital Charge Code |
4506440801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$977.50 |
| Max. Negotiated Rate |
$1,115.50 |
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Health Management Network Commercial |
$977.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,035.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,115.50
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT
|
Facility
|
IP
|
$283.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
4509637201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$240.55 |
| Max. Negotiated Rate |
$274.51 |
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Health Management Network Commercial |
$240.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$254.70
|
| Rate for Payer: MDX Hawaii PPO |
$274.51
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT
|
Facility
|
OP
|
$283.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
4509637201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$87.73 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$141.50
|
| Rate for Payer: AlohaCare Medicare |
$87.73
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Devoted Health Medicare |
$96.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$268.85
|
| Rate for Payer: Health Management Network Commercial |
$240.55
|
| Rate for Payer: Humana Medicare |
$87.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$254.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.73
|
| Rate for Payer: MDX Hawaii PPO |
$274.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.73
|
| Rate for Payer: University Health Alliance Commercial |
$206.28
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
9409637201
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS 96372
|
| Hospital Charge Code |
9409637201
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: AlohaCare Medicaid |
$184.00
|
| Rate for Payer: AlohaCare Medicare |
$114.08
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Devoted Health Medicare |
$125.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$91.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$349.60
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Humana Medicare |
$114.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$187.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.08
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.08
|
| Rate for Payer: University Health Alliance Commercial |
$268.24
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4509637501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$57.04 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$92.00
|
| Rate for Payer: AlohaCare Medicare |
$57.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Devoted Health Medicare |
$62.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.80
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Humana Medicare |
$57.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.04
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.04
|
| Rate for Payer: University Health Alliance Commercial |
$134.12
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
4509637501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$156.40 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG
|
Facility
|
OP
|
$1,089.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
9409637401
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$36.88 |
| Max. Negotiated Rate |
$1,056.33 |
| Rate for Payer: AlohaCare Medicaid |
$544.50
|
| Rate for Payer: AlohaCare Medicare |
$337.59
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Devoted Health Medicare |
$370.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$271.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$337.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,034.55
|
| Rate for Payer: Health Management Network Commercial |
$925.65
|
| Rate for Payer: Humana Medicare |
$337.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$980.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$555.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$337.59
|
| Rate for Payer: MDX Hawaii PPO |
$1,056.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$337.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$337.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$337.59
|
| Rate for Payer: University Health Alliance Commercial |
$793.77
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG
|
Facility
|
IP
|
$1,089.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
9409637401
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$925.65 |
| Max. Negotiated Rate |
$1,056.33 |
| Rate for Payer: Cash Price |
$653.40
|
| Rate for Payer: Health Management Network Commercial |
$925.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$980.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,056.33
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
4509637401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$712.30 |
| Max. Negotiated Rate |
$812.86 |
| Rate for Payer: Cash Price |
$502.80
|
| Rate for Payer: Health Management Network Commercial |
$712.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$754.20
|
| Rate for Payer: MDX Hawaii PPO |
$812.86
|
|
|
HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
HCPCS 96374
|
| Hospital Charge Code |
4509637401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$259.78 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$419.00
|
| Rate for Payer: AlohaCare Medicare |
$259.78
|
| Rate for Payer: Cash Price |
$502.80
|
| Rate for Payer: Cash Price |
$502.80
|
| Rate for Payer: Devoted Health Medicare |
$284.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$259.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$796.10
|
| Rate for Payer: Health Management Network Commercial |
$712.30
|
| Rate for Payer: Humana Medicare |
$259.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$754.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$259.78
|
| Rate for Payer: MDX Hawaii PPO |
$812.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$259.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$259.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$259.78
|
| Rate for Payer: University Health Alliance Commercial |
$610.82
|
|
