|
SARS-COV2/Flu A, B PCR FSI
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS 87636 QW
|
| Hospital Charge Code |
10058644
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$476.85 |
| Max. Negotiated Rate |
$544.17 |
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Health Management Network Commercial |
$476.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.90
|
| Rate for Payer: MDX Hawaii PPO |
$544.17
|
|
|
SARS-COV2/Flu A, B PCR FSI
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS 87636 QW
|
| Hospital Charge Code |
10058644
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$544.17 |
| Rate for Payer: AlohaCare Medicaid |
$280.50
|
| Rate for Payer: AlohaCare Medicare |
$280.50
|
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Devoted Health Medicare |
$308.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$142.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$178.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$280.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$142.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.63
|
| Rate for Payer: Health Management Network Commercial |
$476.85
|
| Rate for Payer: Humana Medicare |
$280.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$286.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$280.50
|
| Rate for Payer: MDX Hawaii PPO |
$544.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$280.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$280.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$280.50
|
| Rate for Payer: University Health Alliance Commercial |
$408.91
|
|
|
SARS CoV-2 RNA (For International Travel Only) FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
9335642
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
SARS CoV-2 RNA (For International Travel Only) FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
9335642
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
SARS ñ CoV-2 Flu A/B, RSV PCR FSI
|
Facility
|
OP
|
$579.00
|
|
|
Service Code
|
HCPCS 87637 QW
|
| Hospital Charge Code |
10026082
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$561.63 |
| Rate for Payer: AlohaCare Medicaid |
$289.50
|
| Rate for Payer: AlohaCare Medicare |
$289.50
|
| Rate for Payer: Cash Price |
$376.35
|
| Rate for Payer: Cash Price |
$376.35
|
| Rate for Payer: Devoted Health Medicare |
$318.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$142.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$178.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$142.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.63
|
| Rate for Payer: Health Management Network Commercial |
$492.15
|
| Rate for Payer: Humana Medicare |
$289.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$521.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$295.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.50
|
| Rate for Payer: MDX Hawaii PPO |
$561.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.50
|
| Rate for Payer: University Health Alliance Commercial |
$422.03
|
|
|
SARS ñ CoV-2 Flu A/B, RSV PCR FSI
|
Facility
|
IP
|
$579.00
|
|
|
Service Code
|
HCPCS 87637 QW
|
| Hospital Charge Code |
10026082
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$492.15 |
| Max. Negotiated Rate |
$561.63 |
| Rate for Payer: Cash Price |
$376.35
|
| Rate for Payer: Health Management Network Commercial |
$492.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$521.10
|
| Rate for Payer: MDX Hawaii PPO |
$561.63
|
|
|
SARS ñ CoV-2 RT-PCR CPH FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635 QW
|
| Hospital Charge Code |
10026135
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
SARS ñ CoV-2 RT-PCR CPH FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635 QW
|
| Hospital Charge Code |
10026135
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
S. cerevisiae IgG/IgA FSI
|
Facility
|
OP
|
$595.00
|
|
|
Service Code
|
HCPCS 86671
|
| Hospital Charge Code |
8331288
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$577.15 |
| Rate for Payer: AlohaCare Medicaid |
$297.50
|
| Rate for Payer: AlohaCare Medicare |
$297.50
|
| Rate for Payer: Cash Price |
$386.75
|
| Rate for Payer: Cash Price |
$386.75
|
| Rate for Payer: Devoted Health Medicare |
$327.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$297.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.25
|
| Rate for Payer: Health Management Network Commercial |
$505.75
|
| Rate for Payer: Humana Medicare |
$297.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$535.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$303.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$297.50
|
| Rate for Payer: MDX Hawaii PPO |
$577.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$297.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$297.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$297.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.69
|
|
|
S. cerevisiae IgG/IgA FSI
|
Facility
|
IP
|
$595.00
|
|
|
Service Code
|
HCPCS 86671
|
| Hospital Charge Code |
8331288
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$505.75 |
| Max. Negotiated Rate |
$577.15 |
| Rate for Payer: Cash Price |
$386.75
|
| Rate for Payer: Health Management Network Commercial |
$505.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$535.50
|
| Rate for Payer: MDX Hawaii PPO |
$577.15
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
IP
|
$124.97
|
|
|
Service Code
|
NDC 10019055303
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.22 |
| Max. Negotiated Rate |
$121.22 |
| Rate for Payer: Cash Price |
$81.23
|
| Rate for Payer: Health Management Network Commercial |
$106.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.47
|
| Rate for Payer: MDX Hawaii PPO |
$121.22
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
OP
|
$114.18
|
|
|
Service Code
|
NDC 00378647097
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.09 |
| Max. Negotiated Rate |
$110.75 |
| Rate for Payer: AlohaCare Medicaid |
$57.09
|
| Rate for Payer: AlohaCare Medicare |
$57.09
|
| Rate for Payer: Cash Price |
$74.22
|
| Rate for Payer: Devoted Health Medicare |
$62.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.47
|
| Rate for Payer: Health Management Network Commercial |
$97.05
|
| Rate for Payer: Humana Medicare |
$57.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.09
|
| Rate for Payer: MDX Hawaii PPO |
$110.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.09
|
| Rate for Payer: University Health Alliance Commercial |
$83.23
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
IP
|
$114.18
|
|
|
Service Code
|
NDC 50742050510
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.05 |
| Max. Negotiated Rate |
$110.75 |
| Rate for Payer: Cash Price |
$74.22
|
| Rate for Payer: Health Management Network Commercial |
$97.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.76
|
| Rate for Payer: MDX Hawaii PPO |
$110.75
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
IP
|
$107.60
|
|
|
Service Code
|
NDC 66758020854
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.46 |
| Max. Negotiated Rate |
$104.37 |
| Rate for Payer: Cash Price |
$69.94
|
| Rate for Payer: Health Management Network Commercial |
$91.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.84
|
| Rate for Payer: MDX Hawaii PPO |
$104.37
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
IP
|
$114.18
|
|
|
Service Code
|
NDC 00378647097
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.05 |
| Max. Negotiated Rate |
$110.75 |
| Rate for Payer: Cash Price |
$74.22
|
| Rate for Payer: Health Management Network Commercial |
$97.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.76
|
| Rate for Payer: MDX Hawaii PPO |
$110.75
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
OP
|
$114.29
|
|
|
Service Code
|
NDC 45802058046
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$110.86 |
| Rate for Payer: AlohaCare Medicaid |
$57.15
|
| Rate for Payer: AlohaCare Medicare |
$57.15
|
| Rate for Payer: Cash Price |
$74.29
|
| Rate for Payer: Devoted Health Medicare |
$62.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.58
|
| Rate for Payer: Health Management Network Commercial |
$97.15
|
| Rate for Payer: Humana Medicare |
$57.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.15
|
| Rate for Payer: MDX Hawaii PPO |
$110.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.15
|
| Rate for Payer: University Health Alliance Commercial |
$83.31
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
IP
|
$114.29
|
|
|
Service Code
|
NDC 45802058046
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.15 |
| Max. Negotiated Rate |
$110.86 |
| Rate for Payer: Cash Price |
$74.29
|
| Rate for Payer: Health Management Network Commercial |
$97.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.86
|
| Rate for Payer: MDX Hawaii PPO |
$110.86
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
OP
|
$124.97
|
|
|
Service Code
|
NDC 10019055303
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.48 |
| Max. Negotiated Rate |
$121.22 |
| Rate for Payer: AlohaCare Medicaid |
$62.48
|
| Rate for Payer: AlohaCare Medicare |
$62.48
|
| Rate for Payer: Cash Price |
$81.23
|
| Rate for Payer: Devoted Health Medicare |
$68.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.72
|
| Rate for Payer: Health Management Network Commercial |
$106.22
|
| Rate for Payer: Humana Medicare |
$62.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.48
|
| Rate for Payer: MDX Hawaii PPO |
$121.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$74.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.48
|
| Rate for Payer: University Health Alliance Commercial |
$91.09
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
OP
|
$114.18
|
|
|
Service Code
|
NDC 50742050510
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.09 |
| Max. Negotiated Rate |
$110.75 |
| Rate for Payer: AlohaCare Medicaid |
$57.09
|
| Rate for Payer: AlohaCare Medicare |
$57.09
|
| Rate for Payer: Cash Price |
$74.22
|
| Rate for Payer: Devoted Health Medicare |
$62.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.47
|
| Rate for Payer: Health Management Network Commercial |
$97.05
|
| Rate for Payer: Humana Medicare |
$57.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.09
|
| Rate for Payer: MDX Hawaii PPO |
$110.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.09
|
| Rate for Payer: University Health Alliance Commercial |
$83.23
|
|
|
scopolamine 1 mg/72 hr patch [HHSC]
|
Facility
|
OP
|
$107.60
|
|
|
Service Code
|
NDC 66758020854
|
| Hospital Charge Code |
2500735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.80 |
| Max. Negotiated Rate |
$104.37 |
| Rate for Payer: AlohaCare Medicaid |
$53.80
|
| Rate for Payer: AlohaCare Medicare |
$53.80
|
| Rate for Payer: Cash Price |
$69.94
|
| Rate for Payer: Devoted Health Medicare |
$59.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.22
|
| Rate for Payer: Health Management Network Commercial |
$91.46
|
| Rate for Payer: Humana Medicare |
$53.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.80
|
| Rate for Payer: MDX Hawaii PPO |
$104.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.80
|
| Rate for Payer: University Health Alliance Commercial |
$78.43
|
|
|
SCREW SPACER/COMPRESSION BOLT, FEM NAIL
|
Facility
|
IP
|
$779.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12991371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$436.24 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$545.30
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: University Health Alliance Commercial |
$436.24
|
|
|
SCREW SPACER/COMPRESSION BOLT, FEM NAIL
|
Facility
|
OP
|
$779.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12991371
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$389.50 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: AlohaCare Medicaid |
$389.50
|
| Rate for Payer: AlohaCare Medicare |
$389.50
|
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Devoted Health Medicare |
$428.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$389.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$545.30
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Humana Medicare |
$389.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$397.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$389.50
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$389.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$389.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$389.50
|
| Rate for Payer: University Health Alliance Commercial |
$436.24
|
|
|
SEAL SET SINGLE USE
|
Facility
|
IP
|
$67.00
|
|
| Hospital Charge Code |
9390157
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
SEAL SET SINGLE USE
|
Facility
|
OP
|
$67.00
|
|
| Hospital Charge Code |
9390157
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.50 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: AlohaCare Medicaid |
$33.50
|
| Rate for Payer: AlohaCare Medicare |
$33.50
|
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Devoted Health Medicare |
$36.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.65
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Humana Medicare |
$33.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.50
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.50
|
| Rate for Payer: University Health Alliance Commercial |
$48.84
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$24,450.66
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$24,450.66 |
| Max. Negotiated Rate |
$24,450.66 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,450.66
|
|
