|
HC OBSERVATION CARVE-OUT - RADIOLOGY
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037802
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$53.94
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Devoted Health Medicare |
$59.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$53.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.94
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.94
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
HC OBSERVATION CARVE-OUT - RESPIRATORY
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037805
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
HC OBSERVATION CARVE-OUT - RESPIRATORY
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037805
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$53.94
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Devoted Health Medicare |
$59.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$53.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.94
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.94
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
HC OBSERVATION CARVE-OUT - SURGICAL
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037806
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$53.94
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Devoted Health Medicare |
$59.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$53.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.94
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.94
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
HC OBSERVATION CARVE-OUT - SURGICAL
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037806
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
HC OBSERVATION HOURLY
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037801
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$53.94
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Devoted Health Medicare |
$59.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$53.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.94
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.94
|
| Rate for Payer: University Health Alliance Commercial |
$126.83
|
|
|
HC OBSERVATION HOURLY
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
762G037801
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
HC OB US LIMITED FETUS(S) - US OB LIMITED 1+ FETUSES
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS 76815
|
| Hospital Charge Code |
4027681501
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$449.65 |
| Max. Negotiated Rate |
$513.13 |
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Health Management Network Commercial |
$449.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$476.10
|
| Rate for Payer: MDX Hawaii PPO |
$513.13
|
|
|
HC OB US LIMITED FETUS(S) - US OB LIMITED 1+ FETUSES
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS 76815
|
| Hospital Charge Code |
4027681501
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$513.13 |
| Rate for Payer: AlohaCare Medicaid |
$264.50
|
| Rate for Payer: AlohaCare Medicare |
$163.99
|
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Devoted Health Medicare |
$179.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$46.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$163.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$449.65
|
| Rate for Payer: Humana Medicare |
$163.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$476.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$269.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$163.99
|
| Rate for Payer: MDX Hawaii PPO |
$513.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$163.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$163.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$163.99
|
| Rate for Payer: University Health Alliance Commercial |
$183.63
|
|
|
HC OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE APPROACHES
|
Facility
|
IP
|
$12,637.00
|
|
|
Service Code
|
HCPCS 21431
|
| Hospital Charge Code |
4502143101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10,741.45 |
| Max. Negotiated Rate |
$12,257.89 |
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Health Management Network Commercial |
$10,741.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,373.30
|
| Rate for Payer: MDX Hawaii PPO |
$12,257.89
|
|
|
HC OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE APPROACHES
|
Facility
|
OP
|
$12,637.00
|
|
|
Service Code
|
HCPCS 21431
|
| Hospital Charge Code |
4502143101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$12,257.89 |
| Rate for Payer: AlohaCare Medicaid |
$6,318.50
|
| Rate for Payer: AlohaCare Medicare |
$3,917.47
|
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Devoted Health Medicare |
$4,296.58
|
| 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 |
$3,917.47
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,005.15
|
| Rate for Payer: Health Management Network Commercial |
$10,741.45
|
| Rate for Payer: Humana Medicare |
$3,917.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,373.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,917.47
|
| Rate for Payer: MDX Hawaii PPO |
$12,257.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,917.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,917.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,917.47
|
| Rate for Payer: University Health Alliance Commercial |
$9,211.11
|
|
|
HC OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH INTERNAL FIXATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 27246
|
| Hospital Charge Code |
4502724601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH INTERNAL FIXATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 27246
|
| Hospital Charge Code |
4502724601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$289.85 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$467.50
|
| Rate for Payer: AlohaCare Medicare |
$289.85
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$317.90
|
| 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 |
$289.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$289.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.85
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.85
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH INTERNAL FIXATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 24576
|
| Hospital Charge Code |
4502457601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH INTERNAL FIXATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 24576
|
| Hospital Charge Code |
4502457601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$289.85 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$467.50
|
| Rate for Payer: AlohaCare Medicare |
$289.85
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$317.90
|
| 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 |
$289.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$289.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.85
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.85
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC OPEN TREATMENT OF HUMERAL SHAFT FRACTURE; WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 24560
|
| Hospital Charge Code |
4502456001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC OPEN TREATMENT OF HUMERAL SHAFT FRACTURE; WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 24560
|
| Hospital Charge Code |
4502456001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$289.85 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$467.50
|
| Rate for Payer: AlohaCare Medicare |
$289.85
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$317.90
|
| 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 |
$289.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$289.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$841.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.85
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.85
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED, MULTIPLE APPROACHES
|
Facility
|
IP
|
$12,637.00
|
|
|
Service Code
|
HCPCS 21421
|
| Hospital Charge Code |
4502142101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10,741.45 |
| Max. Negotiated Rate |
$12,257.89 |
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Health Management Network Commercial |
$10,741.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,373.30
|
| Rate for Payer: MDX Hawaii PPO |
$12,257.89
|
|
|
HC OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED, MULTIPLE APPROACHES
|
Facility
|
OP
|
$12,637.00
|
|
|
Service Code
|
HCPCS 21421
|
| Hospital Charge Code |
4502142101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$12,257.89 |
| Rate for Payer: AlohaCare Medicaid |
$6,318.50
|
| Rate for Payer: AlohaCare Medicare |
$3,917.47
|
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Cash Price |
$7,582.20
|
| Rate for Payer: Devoted Health Medicare |
$4,296.58
|
| 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 |
$3,917.47
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,005.15
|
| Rate for Payer: Health Management Network Commercial |
$10,741.45
|
| Rate for Payer: Humana Medicare |
$3,917.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,373.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,917.47
|
| Rate for Payer: MDX Hawaii PPO |
$12,257.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,917.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,917.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,917.47
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
HC OT MANUAL THER TECH,1+REGIONS,EA 15 MIN
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 97140 GO
|
| Hospital Charge Code |
4309714001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$111.35 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
|
|
HC OT MANUAL THER TECH,1+REGIONS,EA 15 MIN
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 97140 GO
|
| Hospital Charge Code |
4309714001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$20.55 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: AlohaCare Medicaid |
$65.50
|
| Rate for Payer: AlohaCare Medicare |
$40.61
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Devoted Health Medicare |
$44.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.45
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Humana Medicare |
$40.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.61
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.61
|
| Rate for Payer: University Health Alliance Commercial |
$95.49
|
|
|
HC OT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 97112 GO
|
| Hospital Charge Code |
4309711201
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: AlohaCare Medicaid |
$81.50
|
| Rate for Payer: AlohaCare Medicare |
$50.53
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Devoted Health Medicare |
$55.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$154.85
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Humana Medicare |
$50.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.53
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.53
|
| Rate for Payer: University Health Alliance Commercial |
$118.81
|
|
|
HC OT NEUROMUSC REEDUCAT,1+ AREAS, EA 15 MIN
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 97112 GO
|
| Hospital Charge Code |
4309711201
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$138.55 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
|
|
HC OT OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
HCPCS 97167 GO
|
| Hospital Charge Code |
4349716701
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$475.30 |
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Health Management Network Commercial |
$416.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.00
|
| Rate for Payer: MDX Hawaii PPO |
$475.30
|
|
|
HC OT OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
HCPCS 97167 GO
|
| Hospital Charge Code |
4349716701
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$107.85 |
| Max. Negotiated Rate |
$475.30 |
| Rate for Payer: AlohaCare Medicaid |
$245.00
|
| Rate for Payer: AlohaCare Medicare |
$151.90
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Devoted Health Medicare |
$166.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$151.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$465.50
|
| Rate for Payer: Health Management Network Commercial |
$416.50
|
| Rate for Payer: Humana Medicare |
$151.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$249.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$151.90
|
| Rate for Payer: MDX Hawaii PPO |
$475.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$151.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$151.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$151.90
|
| Rate for Payer: University Health Alliance Commercial |
$357.16
|
|
