|
Genital Culture w/ Gram Stain, Aerobic Anaerobic FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117919
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Genital Culture w/ Gram Stain, Aerobic Anaerobic FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117919
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$98.32
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.16 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: AlohaCare Medicaid |
$49.16
|
| Rate for Payer: AlohaCare Medicare |
$49.16
|
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Devoted Health Medicare |
$54.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.40
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Humana Medicare |
$49.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.16
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.16
|
| Rate for Payer: University Health Alliance Commercial |
$71.67
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$197.26
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.67 |
| Max. Negotiated Rate |
$191.34 |
| Rate for Payer: Cash Price |
$128.22
|
| Rate for Payer: Health Management Network Commercial |
$167.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.53
|
| Rate for Payer: MDX Hawaii PPO |
$191.34
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$108.86
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.43 |
| Max. Negotiated Rate |
$105.59 |
| Rate for Payer: AlohaCare Medicaid |
$54.43
|
| Rate for Payer: AlohaCare Medicare |
$54.43
|
| Rate for Payer: Cash Price |
$70.76
|
| Rate for Payer: Devoted Health Medicare |
$59.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.42
|
| Rate for Payer: Health Management Network Commercial |
$92.53
|
| Rate for Payer: Humana Medicare |
$54.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.43
|
| Rate for Payer: MDX Hawaii PPO |
$105.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.43
|
| Rate for Payer: University Health Alliance Commercial |
$79.35
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$98.32
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$197.26
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.63 |
| Max. Negotiated Rate |
$191.34 |
| Rate for Payer: AlohaCare Medicaid |
$98.63
|
| Rate for Payer: AlohaCare Medicare |
$98.63
|
| Rate for Payer: Cash Price |
$128.22
|
| Rate for Payer: Devoted Health Medicare |
$108.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$187.40
|
| Rate for Payer: Health Management Network Commercial |
$167.67
|
| Rate for Payer: Humana Medicare |
$98.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.63
|
| Rate for Payer: MDX Hawaii PPO |
$191.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$118.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.63
|
| Rate for Payer: University Health Alliance Commercial |
$143.78
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$108.86
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$105.59 |
| Rate for Payer: Cash Price |
$70.76
|
| Rate for Payer: Health Management Network Commercial |
$92.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.97
|
| Rate for Payer: MDX Hawaii PPO |
$105.59
|
|
|
gentamicin 80 mg/2ml vial [HHSC]
|
Facility
|
IP
|
$21.55
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Health Management Network Commercial |
$18.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: MDX Hawaii PPO |
$20.90
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
|
|
gentamicin 80 mg/2ml vial [HHSC]
|
Facility
|
OP
|
$8.44
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: AlohaCare Medicaid |
$4.22
|
| Rate for Payer: AlohaCare Medicaid |
$10.78
|
| Rate for Payer: AlohaCare Medicare |
$10.78
|
| Rate for Payer: AlohaCare Medicare |
$4.22
|
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Devoted Health Medicare |
$11.85
|
| Rate for Payer: Devoted Health Medicare |
$4.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.02
|
| Rate for Payer: Health Management Network Commercial |
$18.32
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Humana Medicare |
$10.78
|
| Rate for Payer: Humana Medicare |
$4.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.22
|
| Rate for Payer: MDX Hawaii PPO |
$20.90
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.78
|
| Rate for Payer: University Health Alliance Commercial |
$15.71
|
| Rate for Payer: University Health Alliance Commercial |
$6.15
|
|
|
Gentamicin Peak FSI
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.20 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
|
|
Gentamicin Peak FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
|
gentamicin PED 20 mg/2ml vial [HHSC]
|
Facility
|
IP
|
$26.29
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.35 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Cash Price |
$17.09
|
| Rate for Payer: Health Management Network Commercial |
$22.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.66
|
| Rate for Payer: MDX Hawaii PPO |
$25.50
|
|
|
gentamicin PED 20 mg/2ml vial [HHSC]
|
Facility
|
OP
|
$26.29
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500352
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: AlohaCare Medicaid |
$13.14
|
| Rate for Payer: AlohaCare Medicare |
$13.14
|
| Rate for Payer: Cash Price |
$17.09
|
| Rate for Payer: Cash Price |
$17.09
|
| Rate for Payer: Devoted Health Medicare |
$14.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.98
|
| Rate for Payer: Health Management Network Commercial |
$22.35
|
| Rate for Payer: Humana Medicare |
$13.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.14
|
| Rate for Payer: MDX Hawaii PPO |
$25.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.14
|
| Rate for Payer: University Health Alliance Commercial |
$19.16
|
|
|
Gentamicin Random FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
|
Gentamicin Random FSI
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.20 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
|
|
Gentamicin Trough FSI
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451089
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.20 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
|
|
Gentamicin Trough FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451089
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
|
GGTP (GGT) FSI
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS 82977
|
| Hospital Charge Code |
8117922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$83.42 |
| Rate for Payer: AlohaCare Medicaid |
$43.00
|
| Rate for Payer: AlohaCare Medicare |
$43.00
|
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Devoted Health Medicare |
$47.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Humana Medicare |
$43.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.00
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.61
|
|
|
GGTP (GGT) FSI
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS 82977
|
| Hospital Charge Code |
8117922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.10 |
| Max. Negotiated Rate |
$83.42 |
| Rate for Payer: Cash Price |
$55.90
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
|
|
GHB Screen, Urine w/ Rfx Cnfrm FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8859124
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: AlohaCare Medicaid |
$692.00
|
| Rate for Payer: AlohaCare Medicare |
$692.00
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Devoted Health Medicare |
$761.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$77.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.14
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Humana Medicare |
$692.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$705.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$692.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$692.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$692.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$692.00
|
| Rate for Payer: University Health Alliance Commercial |
$147.65
|
|
|
GHB Screen, Urine w/ Rfx Cnfrm FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8859124
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,176.40 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
|
|
Giardia Lamblia Ag FSI
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS 87329
|
| Hospital Charge Code |
9345653
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: AlohaCare Medicaid |
$69.50
|
| Rate for Payer: AlohaCare Medicare |
$69.50
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Devoted Health Medicare |
$76.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.98
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Humana Medicare |
$69.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.50
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.01
|
|
|
Giardia Lamblia Ag FSI
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS 87329
|
| Hospital Charge Code |
9345653
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$118.15 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
|
|
GI CATHETER, NEEDLE INTERJECT
|
Facility
|
OP
|
$152.00
|
|
| Hospital Charge Code |
8274152
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$76.00 |
| Max. Negotiated Rate |
$147.44 |
| Rate for Payer: AlohaCare Medicaid |
$76.00
|
| Rate for Payer: AlohaCare Medicare |
$76.00
|
| Rate for Payer: Cash Price |
$98.80
|
| Rate for Payer: Devoted Health Medicare |
$83.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.40
|
| Rate for Payer: Health Management Network Commercial |
$129.20
|
| Rate for Payer: Humana Medicare |
$76.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.00
|
| Rate for Payer: MDX Hawaii PPO |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.00
|
| Rate for Payer: University Health Alliance Commercial |
$110.79
|
|
