|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$176.07
|
|
|
Service Code
|
HCPCS 99213
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$42.37 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$66.56
|
| Rate for Payer: AlohaCare Medicare |
$57.69
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Devoted Health Medicare |
$63.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.37
|
| Rate for Payer: Health Management Network Commercial |
$149.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$249.88
|
|
|
Service Code
|
HCPCS 99214
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$63.45 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$98.27
|
| Rate for Payer: AlohaCare Medicare |
$84.69
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: Devoted Health Medicare |
$93.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.45
|
| Rate for Payer: Health Management Network Commercial |
$212.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$110.74
|
|
|
Service Code
|
HCPCS 99212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.59 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$35.51
|
| Rate for Payer: AlohaCare Medicare |
$31.00
|
| Rate for Payer: Cash Price |
$66.44
|
| Rate for Payer: Cash Price |
$66.44
|
| Rate for Payer: Cash Price |
$66.44
|
| Rate for Payer: Devoted Health Medicare |
$34.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.59
|
| Rate for Payer: Health Management Network Commercial |
$94.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$46.74
|
|
|
Service Code
|
HCPCS 99211
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$8.86
|
| Rate for Payer: AlohaCare Medicare |
$7.72
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Devoted Health Medicare |
$8.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.23
|
| Rate for Payer: Health Management Network Commercial |
$39.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$431.43
|
|
|
Service Code
|
HCPCS 99205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$182.72
|
| Rate for Payer: AlohaCare Medicare |
$159.56
|
| Rate for Payer: Cash Price |
$258.86
|
| Rate for Payer: Cash Price |
$258.86
|
| Rate for Payer: Cash Price |
$258.86
|
| Rate for Payer: Devoted Health Medicare |
$175.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.52
|
| Rate for Payer: Health Management Network Commercial |
$366.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$182.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$159.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$215.90
|
|
|
Service Code
|
HCPCS 99203
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$70.97 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$82.26
|
| Rate for Payer: AlohaCare Medicare |
$70.97
|
| Rate for Payer: Cash Price |
$129.54
|
| Rate for Payer: Cash Price |
$129.54
|
| Rate for Payer: Cash Price |
$129.54
|
| Rate for Payer: Devoted Health Medicare |
$78.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.24
|
| Rate for Payer: Health Management Network Commercial |
$183.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$324.26
|
|
|
Service Code
|
HCPCS 99204
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$112.99 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$134.25
|
| Rate for Payer: AlohaCare Medicare |
$116.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Devoted Health Medicare |
$128.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.99
|
| Rate for Payer: Health Management Network Commercial |
$275.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$134.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$116.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$139.81
|
|
|
Service Code
|
HCPCS 99202
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$41.15 |
| Max. Negotiated Rate |
$615.19 |
| Rate for Payer: AlohaCare Medicaid |
$47.75
|
| Rate for Payer: AlohaCare Medicare |
$41.15
|
| Rate for Payer: Cash Price |
$83.89
|
| Rate for Payer: Cash Price |
$83.89
|
| Rate for Payer: Cash Price |
$83.89
|
| Rate for Payer: Devoted Health Medicare |
$45.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$449.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$361.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$449.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.98
|
| Rate for Payer: Health Management Network Commercial |
$118.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$319.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$449.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$361.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
|
|
PROGEL EXTENDED APPLICATOR TIP
|
Facility
|
OP
|
$626.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.06 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: AlohaCare Medicaid |
$313.00
|
| Rate for Payer: AlohaCare Medicare |
$194.06
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Devoted Health Medicare |
$212.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$594.70
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Humana Medicare |
$194.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$319.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.06
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.06
|
| Rate for Payer: University Health Alliance Commercial |
$456.29
|
|
|
PROGEL EXTENDED APPLICATOR TIP
|
Facility
|
IP
|
$626.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.10 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
|
|
PROGEL PLEURAL AIR LEAK SEALAN
|
Facility
|
IP
|
$2,424.00
|
|
|
Service Code
|
HCPCS C2615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,357.44 |
| Max. Negotiated Rate |
$2,351.28 |
| Rate for Payer: Cash Price |
$1,454.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,696.80
|
| Rate for Payer: Health Management Network Commercial |
$2,060.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,181.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,351.28
|
| Rate for Payer: University Health Alliance Commercial |
$1,357.44
|
|
|
PROGEL PLEURAL AIR LEAK SEALAN
|
Facility
|
OP
|
$2,424.00
|
|
|
Service Code
|
HCPCS C2615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$751.44 |
| Max. Negotiated Rate |
$2,351.28 |
| Rate for Payer: AlohaCare Medicaid |
$1,212.00
|
| Rate for Payer: AlohaCare Medicare |
$751.44
|
| Rate for Payer: Cash Price |
$1,454.40
|
| Rate for Payer: Devoted Health Medicare |
$824.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$751.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,696.80
|
| Rate for Payer: Health Management Network Commercial |
$2,060.40
|
| Rate for Payer: Humana Medicare |
$751.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,181.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,236.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$751.44
|
| Rate for Payer: MDX Hawaii PPO |
$2,351.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$751.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$751.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$751.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,357.44
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J2675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$26.04
|
| Rate for Payer: AlohaCare Medicare |
$39.06
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Devoted Health Medicare |
$28.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$39.06
|
| Rate for Payer: Humana Medicare |
$26.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.04
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.04
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J2675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
PROGRAMMER SMART TH90G01
|
Facility
|
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,209.00 |
| Max. Negotiated Rate |
$3,783.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,950.00
|
| Rate for Payer: AlohaCare Medicare |
$1,209.00
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Devoted Health Medicare |
$1,326.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,209.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,730.00
|
| Rate for Payer: Health Management Network Commercial |
$3,315.00
|
| Rate for Payer: Humana Medicare |
$1,209.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,510.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,989.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,209.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,783.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,209.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,209.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,209.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,184.00
|
|
|
PROGRAMMER SMART TH90G01
|
Facility
|
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$3,783.00 |
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,730.00
|
| Rate for Payer: Health Management Network Commercial |
$3,315.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,510.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,783.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,184.00
|
|
|
PROJECTION 440 10721-440HP
|
Facility
|
IP
|
$2,850.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,596.00 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,995.00
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,596.00
|
|
|
PROJECTION 440 10721-440HP
|
Facility
|
OP
|
$2,850.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$883.50 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,425.00
|
| Rate for Payer: AlohaCare Medicare |
$883.50
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Devoted Health Medicare |
$969.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$883.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,995.00
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Humana Medicare |
$883.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,453.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$883.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$883.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$883.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$883.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,596.00
|
|
|
PROJECTION SMH RND 10610-160LP
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$2,182.50 |
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,575.00
|
| Rate for Payer: Health Management Network Commercial |
$1,912.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,025.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,182.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,260.00
|
|
|
PROJECTION SMH RND 10610-160LP
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$697.50 |
| Max. Negotiated Rate |
$2,182.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,125.00
|
| Rate for Payer: AlohaCare Medicare |
$697.50
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Devoted Health Medicare |
$765.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$697.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,575.00
|
| Rate for Payer: Health Management Network Commercial |
$1,912.50
|
| Rate for Payer: Humana Medicare |
$697.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,025.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,147.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$697.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,182.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$697.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$697.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$697.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,260.00
|
|
|
PROJECTION SMT RND 10721-235MP
|
Facility
|
OP
|
$2,685.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$832.35 |
| Max. Negotiated Rate |
$2,604.45 |
| Rate for Payer: AlohaCare Medicaid |
$1,342.50
|
| Rate for Payer: AlohaCare Medicare |
$832.35
|
| Rate for Payer: Cash Price |
$1,611.00
|
| Rate for Payer: Devoted Health Medicare |
$912.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$832.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,879.50
|
| Rate for Payer: Health Management Network Commercial |
$2,282.25
|
| Rate for Payer: Humana Medicare |
$832.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,416.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,369.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$832.35
|
| Rate for Payer: MDX Hawaii PPO |
$2,604.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$832.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$832.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$832.35
|
| Rate for Payer: University Health Alliance Commercial |
$1,503.60
|
|
|
PROJECTION SMT RND 10721-235MP
|
Facility
|
IP
|
$2,685.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,503.60 |
| Max. Negotiated Rate |
$2,604.45 |
| Rate for Payer: Cash Price |
$1,611.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,879.50
|
| Rate for Payer: Health Management Network Commercial |
$2,282.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,416.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,604.45
|
| Rate for Payer: University Health Alliance Commercial |
$1,503.60
|
|
|
PROLENE 6-0 C-1 36" DA 8706H
|
Facility
|
OP
|
$290.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.90 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: AlohaCare Medicaid |
$145.00
|
| Rate for Payer: AlohaCare Medicare |
$89.90
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Devoted Health Medicare |
$98.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$275.50
|
| Rate for Payer: Health Management Network Commercial |
$246.50
|
| Rate for Payer: Humana Medicare |
$89.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$147.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.90
|
| Rate for Payer: MDX Hawaii PPO |
$281.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.90
|
| Rate for Payer: University Health Alliance Commercial |
$211.38
|
|
|
PROLENE 6-0 C-1 36" DA 8706H
|
Facility
|
IP
|
$290.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.50 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Health Management Network Commercial |
$246.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.00
|
| Rate for Payer: MDX Hawaii PPO |
$281.30
|
|
|
PR OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
HCPCS 49905
|
| Min. Negotiated Rate |
$292.24 |
| Max. Negotiated Rate |
$491.30 |
| Rate for Payer: AlohaCare Medicaid |
$338.46
|
| Rate for Payer: AlohaCare Medicare |
$301.34
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Devoted Health Medicare |
$331.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$301.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$292.24
|
| Rate for Payer: Health Management Network Commercial |
$491.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$361.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$361.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$338.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$301.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$338.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$301.34
|
|
