|
PR ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT
|
Professional
|
Both
|
$682.00
|
|
|
Service Code
|
HCPCS 91010
|
| Min. Negotiated Rate |
$127.61 |
| Max. Negotiated Rate |
$579.70 |
| Rate for Payer: AlohaCare Medicaid |
$245.67
|
| Rate for Payer: AlohaCare Medicare |
$272.11
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Cash Price |
$409.20
|
| Rate for Payer: Devoted Health Medicare |
$299.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$272.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.61
|
| Rate for Payer: Health Management Network Commercial |
$579.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$326.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$326.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$326.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$272.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$245.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$272.11
|
|
|
PR ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS 91010 26
|
| Min. Negotiated Rate |
$70.07 |
| Max. Negotiated Rate |
$245.67 |
| Rate for Payer: AlohaCare Medicaid |
$245.67
|
| Rate for Payer: AlohaCare Medicare |
$70.07
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Devoted Health Medicare |
$77.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.61
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$245.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.07
|
|
|
PR ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION
|
Professional
|
Both
|
$861.10
|
|
|
Service Code
|
HCPCS 43236
|
| Min. Negotiated Rate |
$124.82 |
| Max. Negotiated Rate |
$731.93 |
| Rate for Payer: AlohaCare Medicaid |
$139.09
|
| Rate for Payer: AlohaCare Medicare |
$124.82
|
| Rate for Payer: Cash Price |
$516.66
|
| Rate for Payer: Cash Price |
$516.66
|
| Rate for Payer: Devoted Health Medicare |
$137.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$139.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$267.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$124.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$139.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$352.30
|
| Rate for Payer: Health Management Network Commercial |
$731.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$149.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$124.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$139.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$124.82
|
|
|
PR ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC
|
Professional
|
Both
|
$618.50
|
|
|
Service Code
|
HCPCS 43235
|
| Min. Negotiated Rate |
$111.90 |
| Max. Negotiated Rate |
$525.73 |
| Rate for Payer: AlohaCare Medicaid |
$123.38
|
| Rate for Payer: AlohaCare Medicare |
$111.90
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Devoted Health Medicare |
$123.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$123.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$221.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$123.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$232.96
|
| Rate for Payer: Health Management Network Commercial |
$525.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$134.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$123.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$123.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.90
|
|
|
PR ESOPHAGOSCOPY DILATE ESOPHAGUS BALLOON 30 MM
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
HCPCS 43214
|
| Min. Negotiated Rate |
$166.89 |
| Max. Negotiated Rate |
$282.20 |
| Rate for Payer: AlohaCare Medicaid |
$192.88
|
| Rate for Payer: AlohaCare Medicare |
$166.89
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Devoted Health Medicare |
$183.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$166.89
|
| Rate for Payer: Health Management Network Commercial |
$282.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$200.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$200.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$192.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$166.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$192.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$166.89
|
|
|
PR ESOPHAGOSCOPY FLEX BALLOON DILAT <30 MM DIAM
|
Professional
|
Both
|
$1,883.30
|
|
|
Service Code
|
HCPCS 43220
|
| Min. Negotiated Rate |
$106.62 |
| Max. Negotiated Rate |
$1,600.81 |
| Rate for Payer: AlohaCare Medicaid |
$118.66
|
| Rate for Payer: AlohaCare Medicare |
$106.62
|
| Rate for Payer: Cash Price |
$1,129.98
|
| Rate for Payer: Cash Price |
$1,129.98
|
| Rate for Payer: Devoted Health Medicare |
$117.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$118.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$206.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$118.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$162.50
|
| Rate for Payer: Health Management Network Commercial |
$1,600.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$127.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$118.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.62
|
| Rate for Payer: University Health Alliance Commercial |
$156.48
|
|
|
PR ESOPHAGOSCOPY FLEXIBLE REMOVAL FOREIGN BODY
|
Professional
|
Both
|
$837.83
|
|
|
Service Code
|
HCPCS 43215
|
| Min. Negotiated Rate |
$127.47 |
| Max. Negotiated Rate |
$712.16 |
| Rate for Payer: AlohaCare Medicaid |
$140.72
|
| Rate for Payer: AlohaCare Medicare |
$127.47
|
| Rate for Payer: Cash Price |
$502.70
|
| Rate for Payer: Cash Price |
$502.70
|
| Rate for Payer: Devoted Health Medicare |
$140.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$140.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$247.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.47
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$140.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.48
|
| Rate for Payer: Health Management Network Commercial |
$712.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$152.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$140.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$140.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.47
|
| Rate for Payer: University Health Alliance Commercial |
$190.47
|
|
|
PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC
|
Professional
|
Both
|
$552.98
|
|
|
Service Code
|
HCPCS 43200
|
| Min. Negotiated Rate |
$80.16 |
| Max. Negotiated Rate |
$470.03 |
| Rate for Payer: AlohaCare Medicaid |
$88.86
|
| Rate for Payer: AlohaCare Medicare |
$80.16
|
| Rate for Payer: Cash Price |
$331.79
|
| Rate for Payer: Cash Price |
$331.79
|
| Rate for Payer: Devoted Health Medicare |
$88.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$88.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$180.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$88.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$180.70
|
| Rate for Payer: Health Management Network Commercial |
$470.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.16
|
| Rate for Payer: University Health Alliance Commercial |
$116.48
|
|
|
PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY
|
Professional
|
Both
|
$761.93
|
|
|
Service Code
|
HCPCS 43202
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$647.64 |
| Rate for Payer: AlohaCare Medicaid |
$104.00
|
| Rate for Payer: AlohaCare Medicare |
$94.35
|
| Rate for Payer: Cash Price |
$457.16
|
| Rate for Payer: Cash Price |
$457.16
|
| Rate for Payer: Devoted Health Medicare |
$103.78
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$196.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$195.52
|
| Rate for Payer: Health Management Network Commercial |
$647.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$113.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.35
|
| Rate for Payer: University Health Alliance Commercial |
$136.92
|
|
|
PR ESOPHAGOSCOPY RETROGRADE DILATE BALLOON/OTHER
|
Professional
|
Both
|
$2,438.91
|
|
|
Service Code
|
HCPCS 43213
|
| Min. Negotiated Rate |
$223.22 |
| Max. Negotiated Rate |
$2,073.07 |
| Rate for Payer: AlohaCare Medicaid |
$256.29
|
| Rate for Payer: AlohaCare Medicare |
$223.22
|
| Rate for Payer: Cash Price |
$1,463.35
|
| Rate for Payer: Cash Price |
$1,463.35
|
| Rate for Payer: Devoted Health Medicare |
$245.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$256.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$402.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$223.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$256.29
|
| Rate for Payer: Health Management Network Commercial |
$2,073.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$267.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$267.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$256.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$223.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$256.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$223.22
|
| Rate for Payer: University Health Alliance Commercial |
$340.41
|
|
|
PR ESOPHAGOSCOPY RIGID TRANSORAL WITH BIOPSY
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 43193
|
| Min. Negotiated Rate |
$148.15 |
| Max. Negotiated Rate |
$251.60 |
| Rate for Payer: AlohaCare Medicaid |
$172.05
|
| Rate for Payer: AlohaCare Medicare |
$148.15
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Devoted Health Medicare |
$162.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.15
|
| Rate for Payer: Health Management Network Commercial |
$251.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$177.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$177.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$172.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.15
|
|
|
PR ESOPHAGOSCP RIG TRANSORAL HYPOPHARYNX CRV ESOPH
|
Professional
|
Both
|
$956.00
|
|
|
Service Code
|
HCPCS 43180
|
| Min. Negotiated Rate |
$479.90 |
| Max. Negotiated Rate |
$812.60 |
| Rate for Payer: AlohaCare Medicaid |
$558.35
|
| Rate for Payer: AlohaCare Medicare |
$479.90
|
| Rate for Payer: Cash Price |
$573.60
|
| Rate for Payer: Cash Price |
$573.60
|
| Rate for Payer: Devoted Health Medicare |
$527.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$479.90
|
| Rate for Payer: Health Management Network Commercial |
$812.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$575.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$575.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$575.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$558.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$479.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$558.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$479.90
|
|
|
PRESS FIT LG POST DWJ002
|
Facility
|
OP
|
$1,605.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$497.55 |
| Max. Negotiated Rate |
$1,556.85 |
| Rate for Payer: AlohaCare Medicaid |
$802.50
|
| Rate for Payer: AlohaCare Medicare |
$497.55
|
| Rate for Payer: Cash Price |
$963.00
|
| Rate for Payer: Devoted Health Medicare |
$545.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$497.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,364.25
|
| Rate for Payer: Humana Medicare |
$497.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,444.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$818.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$497.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,556.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$497.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$497.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$497.55
|
| Rate for Payer: University Health Alliance Commercial |
$898.80
|
|
|
PRESS FIT LG POST DWJ002
|
Facility
|
IP
|
$1,605.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$898.80 |
| Max. Negotiated Rate |
$1,556.85 |
| Rate for Payer: Cash Price |
$963.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,123.50
|
| Rate for Payer: Health Management Network Commercial |
$1,364.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,444.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,556.85
|
| Rate for Payer: University Health Alliance Commercial |
$898.80
|
|
|
PRE-SUTURED TENDON FCONEXT
|
Facility
|
OP
|
$2,032.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$629.92 |
| Max. Negotiated Rate |
$1,971.04 |
| Rate for Payer: AlohaCare Medicaid |
$1,016.00
|
| Rate for Payer: AlohaCare Medicare |
$629.92
|
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Devoted Health Medicare |
$690.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$629.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,422.40
|
| Rate for Payer: Health Management Network Commercial |
$1,727.20
|
| Rate for Payer: Humana Medicare |
$629.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,828.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,036.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$629.92
|
| Rate for Payer: MDX Hawaii PPO |
$1,971.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$629.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$629.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$629.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,137.92
|
|
|
PRE-SUTURED TENDON FCONEXT
|
Facility
|
IP
|
$2,032.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,137.92 |
| Max. Negotiated Rate |
$1,971.04 |
| Rate for Payer: Cash Price |
$1,219.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,422.40
|
| Rate for Payer: Health Management Network Commercial |
$1,727.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,828.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,971.04
|
| Rate for Payer: University Health Alliance Commercial |
$1,137.92
|
|
|
PR EVACUATION SUBUNGUAL HEMATOMA
|
Professional
|
Both
|
$110.44
|
|
|
Service Code
|
HCPCS 11740
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$93.87 |
| Rate for Payer: AlohaCare Medicaid |
$34.68
|
| Rate for Payer: AlohaCare Medicare |
$33.49
|
| Rate for Payer: Cash Price |
$66.26
|
| Rate for Payer: Cash Price |
$66.26
|
| Rate for Payer: Devoted Health Medicare |
$36.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$34.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$34.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.98
|
| Rate for Payer: Health Management Network Commercial |
$93.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.49
|
| Rate for Payer: University Health Alliance Commercial |
$38.23
|
|
|
PR EVAL&/FITG VOICE PROSTC DEV SUPLMNT ORAL SPEEC
|
Professional
|
Both
|
$131.06
|
|
|
Service Code
|
HCPCS 92597
|
| Min. Negotiated Rate |
$44.60 |
| Max. Negotiated Rate |
$111.40 |
| Rate for Payer: AlohaCare Medicare |
$74.89
|
| Rate for Payer: Cash Price |
$78.64
|
| Rate for Payer: Cash Price |
$78.64
|
| Rate for Payer: Devoted Health Medicare |
$82.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.60
|
| Rate for Payer: Health Management Network Commercial |
$111.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.89
|
|
|
PREVALON AIRTAP SHEET XXL
|
Facility
|
OP
|
$678.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.18 |
| Max. Negotiated Rate |
$657.66 |
| Rate for Payer: AlohaCare Medicaid |
$339.00
|
| Rate for Payer: AlohaCare Medicare |
$210.18
|
| Rate for Payer: Cash Price |
$406.80
|
| Rate for Payer: Devoted Health Medicare |
$230.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$210.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$644.10
|
| Rate for Payer: Health Management Network Commercial |
$576.30
|
| Rate for Payer: Humana Medicare |
$210.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$610.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$345.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$210.18
|
| Rate for Payer: MDX Hawaii PPO |
$657.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$210.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$210.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$210.18
|
| Rate for Payer: University Health Alliance Commercial |
$494.19
|
|
|
PREVALON AIRTAP SHEET XXL
|
Facility
|
IP
|
$678.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$576.30 |
| Max. Negotiated Rate |
$657.66 |
| Rate for Payer: Cash Price |
$406.80
|
| Rate for Payer: Health Management Network Commercial |
$576.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$610.20
|
| Rate for Payer: MDX Hawaii PPO |
$657.66
|
|
|
PREVALON AIRTAP WEDGE 2XL
|
Facility
|
OP
|
$415.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.65 |
| Max. Negotiated Rate |
$402.55 |
| Rate for Payer: AlohaCare Medicaid |
$207.50
|
| Rate for Payer: AlohaCare Medicare |
$128.65
|
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Devoted Health Medicare |
$141.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$394.25
|
| Rate for Payer: Health Management Network Commercial |
$352.75
|
| Rate for Payer: Humana Medicare |
$128.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$373.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$211.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.65
|
| Rate for Payer: MDX Hawaii PPO |
$402.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.65
|
| Rate for Payer: University Health Alliance Commercial |
$302.49
|
|
|
PREVALON AIRTAP WEDGE 2XL
|
Facility
|
IP
|
$415.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$352.75 |
| Max. Negotiated Rate |
$402.55 |
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Health Management Network Commercial |
$352.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$373.50
|
| Rate for Payer: MDX Hawaii PPO |
$402.55
|
|
|
PREVALON TRANSFER SYSTEM
|
Facility
|
IP
|
$382.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$324.70 |
| Max. Negotiated Rate |
$370.54 |
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Health Management Network Commercial |
$324.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$343.80
|
| Rate for Payer: MDX Hawaii PPO |
$370.54
|
|
|
PREVALON TRANSFER SYSTEM
|
Facility
|
OP
|
$382.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$118.42 |
| Max. Negotiated Rate |
$370.54 |
| Rate for Payer: AlohaCare Medicaid |
$191.00
|
| Rate for Payer: AlohaCare Medicare |
$118.42
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Devoted Health Medicare |
$129.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$362.90
|
| Rate for Payer: Health Management Network Commercial |
$324.70
|
| Rate for Payer: Humana Medicare |
$118.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$343.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.42
|
| Rate for Payer: MDX Hawaii PPO |
$370.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.42
|
| Rate for Payer: University Health Alliance Commercial |
$278.44
|
|
|
PR EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 34808
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$290.15 |
| Rate for Payer: AlohaCare Medicaid |
$185.45
|
| Rate for Payer: AlohaCare Medicare |
$169.00
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Devoted Health Medicare |
$185.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.00
|
| Rate for Payer: Health Management Network Commercial |
$268.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$202.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$202.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$185.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$185.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.00
|
| Rate for Payer: University Health Alliance Commercial |
$290.15
|
|
