|
Miscellaneous Culture FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117996
|
|
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
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$21,748.09
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$21,748.09 |
| Max. Negotiated Rate |
$21,748.09 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,748.09
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$16,929.34
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$16,929.34 |
| Max. Negotiated Rate |
$16,929.34 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16,929.34
|
|
|
misoprostol 100 mcg tablet [HHSC]
|
Facility
|
OP
|
$13.78
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$13.37 |
| Rate for Payer: AlohaCare Medicaid |
$6.89
|
| Rate for Payer: AlohaCare Medicaid |
$4.54
|
| Rate for Payer: AlohaCare Medicaid |
$2.29
|
| Rate for Payer: AlohaCare Medicare |
$2.29
|
| Rate for Payer: AlohaCare Medicare |
$6.89
|
| Rate for Payer: AlohaCare Medicare |
$4.54
|
| Rate for Payer: Cash Price |
$5.91
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Devoted Health Medicare |
$7.58
|
| Rate for Payer: Devoted Health Medicare |
$5.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.35
|
| Rate for Payer: Health Management Network Commercial |
$11.71
|
| Rate for Payer: Health Management Network Commercial |
$3.89
|
| Rate for Payer: Health Management Network Commercial |
$7.73
|
| Rate for Payer: Humana Medicare |
$2.29
|
| Rate for Payer: Humana Medicare |
$4.54
|
| Rate for Payer: Humana Medicare |
$6.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.54
|
| Rate for Payer: MDX Hawaii PPO |
$13.37
|
| Rate for Payer: MDX Hawaii PPO |
$4.44
|
| Rate for Payer: MDX Hawaii PPO |
$8.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.29
|
| Rate for Payer: University Health Alliance Commercial |
$3.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.04
|
| Rate for Payer: University Health Alliance Commercial |
$6.63
|
|
|
misoprostol 100 mcg tablet [HHSC]
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500557
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$5.91
|
| Rate for Payer: Health Management Network Commercial |
$7.73
|
| Rate for Payer: Health Management Network Commercial |
$11.71
|
| Rate for Payer: Health Management Network Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.12
|
| Rate for Payer: MDX Hawaii PPO |
$4.44
|
| Rate for Payer: MDX Hawaii PPO |
$13.37
|
| Rate for Payer: MDX Hawaii PPO |
$8.82
|
|
|
misoprostol 200 mcg tablet [HHSC]
|
Facility
|
IP
|
$7.95
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501057
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Health Management Network Commercial |
$6.76
|
| Rate for Payer: Health Management Network Commercial |
$12.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.63
|
| Rate for Payer: MDX Hawaii PPO |
$14.70
|
| Rate for Payer: MDX Hawaii PPO |
$7.71
|
|
|
misoprostol 200 mcg tablet [HHSC]
|
Facility
|
OP
|
$15.15
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$14.70 |
| Rate for Payer: AlohaCare Medicaid |
$7.58
|
| Rate for Payer: AlohaCare Medicaid |
$3.98
|
| Rate for Payer: AlohaCare Medicare |
$7.58
|
| Rate for Payer: AlohaCare Medicare |
$3.98
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Devoted Health Medicare |
$8.33
|
| Rate for Payer: Devoted Health Medicare |
$4.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.39
|
| Rate for Payer: Health Management Network Commercial |
$12.88
|
| Rate for Payer: Health Management Network Commercial |
$6.76
|
| Rate for Payer: Humana Medicare |
$3.98
|
| Rate for Payer: Humana Medicare |
$7.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.58
|
| Rate for Payer: MDX Hawaii PPO |
$7.71
|
| Rate for Payer: MDX Hawaii PPO |
$14.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.98
|
| Rate for Payer: University Health Alliance Commercial |
$5.79
|
| Rate for Payer: University Health Alliance Commercial |
$11.04
|
|
|
Moderna Vaccine 1st Dose: 0011A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS 0011A
|
| Hospital Charge Code |
9250681
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
Moderna Vaccine 1st Dose: 0011A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS 0011A
|
| Hospital Charge Code |
9250681
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$71.00 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$71.00
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$78.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$71.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.00
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.00
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
|
|
Moderna Vaccine 2nd dose: 0012A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS 0012A
|
| Hospital Charge Code |
9250680
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$71.00 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$71.00
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$78.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$71.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.00
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.00
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
|
|
Moderna Vaccine 2nd dose: 0012A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS 0012A
|
| Hospital Charge Code |
9250680
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
Moderna Vaccine 3rd Dose: 0013A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS 0013A
|
| Hospital Charge Code |
9687165
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$71.00 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$71.00
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$78.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$71.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.00
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.00
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
|
|
Moderna Vaccine 3rd Dose: 0013A - 100mcg - Moderna Vaccine Admin Charge
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS 0013A
|
| Hospital Charge Code |
9687165
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
Mod Sed Different Phys, ea addtl 15 min, 5/> years Charge
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
8704044
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: AlohaCare Medicaid |
$43.50
|
| Rate for Payer: AlohaCare Medicare |
$43.50
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Devoted Health Medicare |
$47.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Humana Medicare |
$43.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.50
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.50
|
| Rate for Payer: University Health Alliance Commercial |
$63.41
|
|
|
Mod Sed Different Phys, ea addtl 15 min, 5/> years Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 99157
|
| Hospital Charge Code |
8704044
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$73.95 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
|
|
Mod Sed Different Phys, initial 15 min, 5/> years charge
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
8704043
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$53.37 |
| Max. Negotiated Rate |
$144.53 |
| Rate for Payer: AlohaCare Medicaid |
$74.50
|
| Rate for Payer: AlohaCare Medicare |
$74.50
|
| Rate for Payer: Cash Price |
$96.85
|
| Rate for Payer: Cash Price |
$96.85
|
| Rate for Payer: Devoted Health Medicare |
$81.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.55
|
| Rate for Payer: Health Management Network Commercial |
$126.65
|
| Rate for Payer: Humana Medicare |
$74.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.50
|
| Rate for Payer: MDX Hawaii PPO |
$144.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.50
|
| Rate for Payer: University Health Alliance Commercial |
$108.61
|
|
|
Mod Sed Different Phys, initial 15 min, 5/> years charge
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
8704043
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$126.65 |
| Max. Negotiated Rate |
$144.53 |
| Rate for Payer: Cash Price |
$96.85
|
| Rate for Payer: Health Management Network Commercial |
$126.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.10
|
| Rate for Payer: MDX Hawaii PPO |
$144.53
|
|
|
Mod Sed Different Phys,, initial 15 mins, less than 5 years old Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 99155
|
| Hospital Charge Code |
8704042
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$138.55 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
|
|
Mod Sed Different Phys,, initial 15 mins, less than 5 years old Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 99155
|
| Hospital Charge Code |
8704042
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$59.68 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: AlohaCare Medicaid |
$81.50
|
| Rate for Payer: AlohaCare Medicare |
$81.50
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Devoted Health Medicare |
$89.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$154.85
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Humana Medicare |
$81.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.50
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.50
|
| Rate for Payer: University Health Alliance Commercial |
$118.81
|
|
|
Mod Sed Same Phys, ea addtl 15 min, 5/> years Charge
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
8386868
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
|
|
Mod Sed Same Phys, ea addtl 15 min, 5/> years Charge
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
8386868
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicare |
$64.50
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Devoted Health Medicare |
$70.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.55
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Humana Medicare |
$64.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.50
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
|
|
Mod Sed Same Phys, initial 15 min, 5/> years charge
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
8386867
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: AlohaCare Medicaid |
$106.00
|
| Rate for Payer: AlohaCare Medicare |
$106.00
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Devoted Health Medicare |
$116.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$201.40
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Humana Medicare |
$106.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.00
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.00
|
| Rate for Payer: University Health Alliance Commercial |
$154.53
|
|
|
Mod Sed Same Phys, initial 15 min, 5/> years charge
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
8386867
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.20 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
|
|
Mod Sed Same Phys,, initial 15 mins, less than 5 years old Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
8386866
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$17.23 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: AlohaCare Medicaid |
$81.50
|
| Rate for Payer: AlohaCare Medicare |
$81.50
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Devoted Health Medicare |
$89.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$154.85
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Humana Medicare |
$81.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.50
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.50
|
| Rate for Payer: University Health Alliance Commercial |
$118.81
|
|
|
Mod Sed Same Phys,, initial 15 mins, less than 5 years old Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
8386866
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$138.55 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Cash Price |
$105.95
|
| Rate for Payer: Health Management Network Commercial |
$138.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.70
|
| Rate for Payer: MDX Hawaii PPO |
$158.11
|
|
