|
PR WET MOUNTS/ W PREPARATIONS
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS Q0111
|
| Min. Negotiated Rate |
$5.90 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: AlohaCare Medicaid |
$5.90
|
| Rate for Payer: AlohaCare Medicare |
$18.54
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$20.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.50
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.54
|
|
|
PR WHFO W/O JOINTS PRE CST
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
HCPCS L3807
|
| Min. Negotiated Rate |
$107.29 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: AlohaCare Medicaid |
$107.29
|
| Rate for Payer: AlohaCare Medicare |
$272.97
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Devoted Health Medicare |
$300.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$272.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$178.81
|
| Rate for Payer: Health Management Network Commercial |
$397.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$327.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$327.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$272.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$272.97
|
|
|
PR WHFO W/O JOINTS PRE OTS
|
Professional
|
Both
|
$468.00
|
|
|
Service Code
|
HCPCS L3809
|
| Min. Negotiated Rate |
$209.46 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: AlohaCare Medicaid |
$209.46
|
| Rate for Payer: AlohaCare Medicare |
$272.97
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Devoted Health Medicare |
$300.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$272.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$209.46
|
| Rate for Payer: Health Management Network Commercial |
$397.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$327.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$327.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$209.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$272.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$209.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$272.97
|
|
|
PR WHO COCK-UP NONMOLDE PRE OTS
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
HCPCS L3908
|
| Min. Negotiated Rate |
$49.46 |
| Max. Negotiated Rate |
$183.60 |
| Rate for Payer: AlohaCare Medicaid |
$49.46
|
| Rate for Payer: AlohaCare Medicare |
$125.86
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Devoted Health Medicare |
$138.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$125.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.02
|
| Rate for Payer: Health Management Network Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$151.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$125.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$125.86
|
|
|
PR WHO NONTORSION JNTS PRE CST
|
Professional
|
Both
|
$996.00
|
|
|
Service Code
|
HCPCS L3915
|
| Min. Negotiated Rate |
$35.68 |
| Max. Negotiated Rate |
$846.60 |
| Rate for Payer: AlohaCare Medicaid |
$35.68
|
| Rate for Payer: AlohaCare Medicare |
$580.28
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Devoted Health Medicare |
$638.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$580.28
|
| Rate for Payer: Health Management Network Commercial |
$846.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$696.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$696.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$696.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$580.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$580.28
|
|
|
PR WHO NONTORSION JNTS PRE OTS
|
Professional
|
Both
|
$996.00
|
|
|
Service Code
|
HCPCS L3916
|
| Min. Negotiated Rate |
$137.16 |
| Max. Negotiated Rate |
$846.60 |
| Rate for Payer: AlohaCare Medicaid |
$445.26
|
| Rate for Payer: AlohaCare Medicare |
$580.28
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Devoted Health Medicare |
$638.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$580.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.16
|
| Rate for Payer: Health Management Network Commercial |
$846.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$696.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$696.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$696.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$445.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$580.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$445.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$580.28
|
|
|
PR WINDOWING CAST
|
Professional
|
Both
|
$123.83
|
|
|
Service Code
|
HCPCS 29730
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: AlohaCare Medicaid |
$44.99
|
| Rate for Payer: AlohaCare Medicare |
$38.48
|
| Rate for Payer: Cash Price |
$74.30
|
| Rate for Payer: Cash Price |
$74.30
|
| Rate for Payer: Devoted Health Medicare |
$42.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$44.99
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$69.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$44.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.80
|
| Rate for Payer: Health Management Network Commercial |
$105.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.48
|
| Rate for Payer: University Health Alliance Commercial |
$58.46
|
|
|
PR XTRNL CANNULA DECLTNG SPX W/O BALO CATH
|
Professional
|
Both
|
$482.07
|
|
|
Service Code
|
HCPCS 36860
|
| Min. Negotiated Rate |
$93.18 |
| Max. Negotiated Rate |
$409.76 |
| Rate for Payer: AlohaCare Medicaid |
$104.73
|
| Rate for Payer: AlohaCare Medicare |
$93.18
|
| Rate for Payer: Cash Price |
$289.24
|
| Rate for Payer: Cash Price |
$289.24
|
| Rate for Payer: Devoted Health Medicare |
$102.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$167.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.04
|
| Rate for Payer: Health Management Network Commercial |
$409.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.18
|
| Rate for Payer: University Health Alliance Commercial |
$152.02
|
|
|
PR XTRNL ECG REC>48HR<7D RECORDING SCAN A/R R&I
|
Professional
|
Both
|
$551.00
|
|
|
Service Code
|
HCPCS 93241
|
| Min. Negotiated Rate |
$97.22 |
| Max. Negotiated Rate |
$468.35 |
| Rate for Payer: AlohaCare Medicaid |
$293.15
|
| Rate for Payer: AlohaCare Medicare |
$314.50
|
| Rate for Payer: Cash Price |
$330.60
|
| Rate for Payer: Cash Price |
$330.60
|
| Rate for Payer: Devoted Health Medicare |
$345.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$314.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.22
|
| Rate for Payer: Health Management Network Commercial |
$468.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$377.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$377.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$377.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$293.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$314.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$293.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$314.50
|
|
|
PR XTRNL ECG REC<48 HRS RECORDING
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 93225
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: AlohaCare Medicaid |
$20.84
|
| Rate for Payer: AlohaCare Medicare |
$20.32
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Devoted Health Medicare |
$22.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.62
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.32
|
|
|
PR XTRNL ECG REC<48 HRS RECORDING SCAN A/R R&I
|
Professional
|
Both
|
$136.20
|
|
|
Service Code
|
HCPCS 93224
|
| Min. Negotiated Rate |
$77.83 |
| Max. Negotiated Rate |
$183.11 |
| Rate for Payer: AlohaCare Medicaid |
$80.09
|
| Rate for Payer: AlohaCare Medicare |
$77.83
|
| Rate for Payer: Cash Price |
$81.72
|
| Rate for Payer: Cash Price |
$81.72
|
| Rate for Payer: Devoted Health Medicare |
$85.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$183.11
|
| Rate for Payer: Health Management Network Commercial |
$115.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$80.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.83
|
|
|
PR XTRNL ECG REC<48 HRS RVW&INTERPJ PHYS/QHP
|
Professional
|
Both
|
$31.85
|
|
|
Service Code
|
HCPCS 93227
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: AlohaCare Medicaid |
$18.52
|
| Rate for Payer: AlohaCare Medicare |
$18.20
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Cash Price |
$19.11
|
| Rate for Payer: Devoted Health Medicare |
$20.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.06
|
| Rate for Payer: Health Management Network Commercial |
$27.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.20
|
|
|
PR XTRNL MOBILE CV TELEMETRY W/I&REPORT 30 DAYS
|
Professional
|
Both
|
$45.10
|
|
|
Service Code
|
HCPCS 93228
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$38.34 |
| Rate for Payer: AlohaCare Medicaid |
$25.34
|
| Rate for Payer: AlohaCare Medicare |
$25.77
|
| Rate for Payer: Cash Price |
$27.06
|
| Rate for Payer: Cash Price |
$27.06
|
| Rate for Payer: Devoted Health Medicare |
$28.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.99
|
| Rate for Payer: Health Management Network Commercial |
$38.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.77
|
|
|
PR XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS
|
Professional
|
Both
|
$274.15
|
|
|
Service Code
|
HCPCS 93271
|
| Min. Negotiated Rate |
$101.38 |
| Max. Negotiated Rate |
$233.03 |
| Rate for Payer: AlohaCare Medicaid |
$163.89
|
| Rate for Payer: AlohaCare Medicare |
$156.28
|
| Rate for Payer: Cash Price |
$164.49
|
| Rate for Payer: Cash Price |
$164.49
|
| Rate for Payer: Devoted Health Medicare |
$171.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.38
|
| Rate for Payer: Health Management Network Commercial |
$233.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$187.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$187.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$163.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$163.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.28
|
|
|
PR XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS
|
Professional
|
Both
|
$16.29
|
|
|
Service Code
|
HCPCS 93270
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: AlohaCare Medicaid |
$9.37
|
| Rate for Payer: AlohaCare Medicare |
$9.31
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Devoted Health Medicare |
$10.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.62
|
| Rate for Payer: Health Management Network Commercial |
$13.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.31
|
|
|
PR XTRNL PT ACTIV ECG TRANSMIS W/R&I </30 DAYS
|
Professional
|
Both
|
$333.00
|
|
|
Service Code
|
HCPCS 93268
|
| Min. Negotiated Rate |
$120.23 |
| Max. Negotiated Rate |
$283.05 |
| Rate for Payer: AlohaCare Medicaid |
$197.44
|
| Rate for Payer: AlohaCare Medicare |
$189.84
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Devoted Health Medicare |
$208.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$189.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.23
|
| Rate for Payer: Health Management Network Commercial |
$283.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$227.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$227.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$227.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$197.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$189.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$197.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$189.84
|
|
|
PR XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS
|
Professional
|
Both
|
$42.46
|
|
|
Service Code
|
HCPCS 93272
|
| Min. Negotiated Rate |
$24.19 |
| Max. Negotiated Rate |
$36.09 |
| Rate for Payer: AlohaCare Medicaid |
$24.19
|
| Rate for Payer: AlohaCare Medicare |
$24.26
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Devoted Health Medicare |
$26.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.14
|
| Rate for Payer: Health Management Network Commercial |
$36.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.26
|
|
|
PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENT
|
Professional
|
Both
|
$911.31
|
|
|
Service Code
|
HCPCS 41016
|
| Min. Negotiated Rate |
$229.32 |
| Max. Negotiated Rate |
$774.61 |
| Rate for Payer: AlohaCare Medicaid |
$366.26
|
| Rate for Payer: AlohaCare Medicare |
$340.74
|
| Rate for Payer: Cash Price |
$546.79
|
| Rate for Payer: Cash Price |
$546.79
|
| Rate for Payer: Devoted Health Medicare |
$374.81
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$366.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$569.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$340.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$366.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$229.32
|
| Rate for Payer: Health Management Network Commercial |
$774.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$408.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$408.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$408.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$366.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$340.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$366.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$340.74
|
| Rate for Payer: University Health Alliance Commercial |
$482.07
|
|
|
PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB
|
Professional
|
Both
|
$903.00
|
|
|
Service Code
|
HCPCS 41017
|
| Min. Negotiated Rate |
$167.70 |
| Max. Negotiated Rate |
$767.55 |
| Rate for Payer: AlohaCare Medicaid |
$364.36
|
| Rate for Payer: AlohaCare Medicare |
$336.37
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Devoted Health Medicare |
$370.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$364.36
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$560.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$336.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$364.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$167.70
|
| Rate for Payer: Health Management Network Commercial |
$767.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$403.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$403.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$403.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$364.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$336.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$364.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$336.37
|
| Rate for Payer: University Health Alliance Commercial |
$474.24
|
|
|
PSEUDOEPHEDRINE 30 MG TABLET [6714]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904699061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
PSEUDOEPHEDRINE 30 MG TABLET [6714]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904699061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
PS FEMORAL SZ #2 5515-F-202
|
Facility
|
OP
|
$4,325.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,340.75 |
| Max. Negotiated Rate |
$4,195.25 |
| Rate for Payer: AlohaCare Medicaid |
$2,162.50
|
| Rate for Payer: AlohaCare Medicare |
$1,340.75
|
| Rate for Payer: Cash Price |
$2,595.00
|
| Rate for Payer: Devoted Health Medicare |
$1,470.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,340.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,027.50
|
| Rate for Payer: Health Management Network Commercial |
$3,676.25
|
| Rate for Payer: Humana Medicare |
$1,340.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,892.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,205.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,340.75
|
| Rate for Payer: MDX Hawaii PPO |
$4,195.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,340.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,340.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,340.75
|
| Rate for Payer: University Health Alliance Commercial |
$2,422.00
|
|
|
PS FEMORAL SZ #2 5515-F-202
|
Facility
|
IP
|
$4,325.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,422.00 |
| Max. Negotiated Rate |
$4,195.25 |
| Rate for Payer: Cash Price |
$2,595.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,027.50
|
| Rate for Payer: Health Management Network Commercial |
$3,676.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,892.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,195.25
|
| Rate for Payer: University Health Alliance Commercial |
$2,422.00
|
|
|
PSN ALL POLY PAT PLY 26MM
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: AlohaCare Medicaid |
$750.00
|
| Rate for Payer: AlohaCare Medicare |
$465.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Devoted Health Medicare |
$510.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$465.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Humana Medicare |
$465.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$765.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$465.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$465.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$465.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$465.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
|
PSN ALL POLY PAT PLY 26MM
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
