|
Testosterone, Free & Total FSI
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
8118056
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$242.25 |
| Max. Negotiated Rate |
$276.45 |
| Rate for Payer: Cash Price |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$242.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$256.50
|
| Rate for Payer: MDX Hawaii PPO |
$276.45
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 0.5ml [HHSC]
|
Facility
|
IP
|
$283.62
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
2500814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.08 |
| Max. Negotiated Rate |
$275.11 |
| Rate for Payer: Cash Price |
$184.35
|
| Rate for Payer: Cash Price |
$193.78
|
| Rate for Payer: Health Management Network Commercial |
$253.41
|
| Rate for Payer: Health Management Network Commercial |
$241.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.32
|
| Rate for Payer: MDX Hawaii PPO |
$275.11
|
| Rate for Payer: MDX Hawaii PPO |
$289.19
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 0.5ml [HHSC]
|
Facility
|
OP
|
$298.13
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
2500814
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.63 |
| Max. Negotiated Rate |
$289.19 |
| Rate for Payer: AlohaCare Medicaid |
$149.06
|
| Rate for Payer: AlohaCare Medicaid |
$141.81
|
| Rate for Payer: AlohaCare Medicare |
$141.81
|
| Rate for Payer: AlohaCare Medicare |
$149.06
|
| Rate for Payer: Cash Price |
$184.35
|
| Rate for Payer: Cash Price |
$184.35
|
| Rate for Payer: Cash Price |
$193.78
|
| Rate for Payer: Cash Price |
$193.78
|
| Rate for Payer: Devoted Health Medicare |
$155.99
|
| Rate for Payer: Devoted Health Medicare |
$163.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$38.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$38.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$141.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$149.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$38.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$38.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$283.22
|
| Rate for Payer: Health Management Network Commercial |
$241.08
|
| Rate for Payer: Health Management Network Commercial |
$253.41
|
| Rate for Payer: Humana Medicare |
$141.81
|
| Rate for Payer: Humana Medicare |
$149.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$152.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$141.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.06
|
| Rate for Payer: MDX Hawaii PPO |
$275.11
|
| Rate for Payer: MDX Hawaii PPO |
$289.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$149.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$141.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$141.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$149.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$170.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$178.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$149.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$141.81
|
| Rate for Payer: University Health Alliance Commercial |
$206.73
|
| Rate for Payer: University Health Alliance Commercial |
$217.31
|
|
|
Tetanus IgG Antibody FSI
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
9960211
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$144.50 |
| Max. Negotiated Rate |
$164.90 |
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Health Management Network Commercial |
$144.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.00
|
| Rate for Payer: MDX Hawaii PPO |
$164.90
|
|
|
Tetanus IgG Antibody FSI
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
9960211
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.41 |
| Max. Negotiated Rate |
$164.90 |
| Rate for Payer: AlohaCare Medicaid |
$85.00
|
| Rate for Payer: AlohaCare Medicare |
$85.00
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Devoted Health Medicare |
$93.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.80
|
| Rate for Payer: Health Management Network Commercial |
$144.50
|
| Rate for Payer: Humana Medicare |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.00
|
| Rate for Payer: MDX Hawaii PPO |
$164.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.00
|
| Rate for Payer: University Health Alliance Commercial |
$38.26
|
|
|
tetanus immune glob 250 unit/1ml syringe [HHSC]
|
Facility
|
OP
|
$1,570.99
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
2500813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$577.05 |
| Max. Negotiated Rate |
$1,523.86 |
| Rate for Payer: AlohaCare Medicaid |
$785.50
|
| Rate for Payer: AlohaCare Medicare |
$785.50
|
| Rate for Payer: Cash Price |
$1,021.14
|
| Rate for Payer: Cash Price |
$1,021.14
|
| Rate for Payer: Devoted Health Medicare |
$864.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$577.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$697.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$785.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$577.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,492.44
|
| Rate for Payer: Health Management Network Commercial |
$1,335.34
|
| Rate for Payer: Humana Medicare |
$785.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,413.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$801.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$785.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,523.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$785.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$785.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$942.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$785.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,145.09
|
|
|
tetanus immune glob 250 unit/1ml syringe [HHSC]
|
Facility
|
IP
|
$1,570.99
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
2500813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,335.34 |
| Max. Negotiated Rate |
$1,523.86 |
| Rate for Payer: Cash Price |
$1,021.14
|
| Rate for Payer: Health Management Network Commercial |
$1,335.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,413.89
|
| Rate for Payer: MDX Hawaii PPO |
$1,523.86
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
OP
|
$61.01
|
|
|
Service Code
|
NDC 24208092064
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: AlohaCare Medicaid |
$30.50
|
| Rate for Payer: AlohaCare Medicare |
$30.50
|
| Rate for Payer: Cash Price |
$39.66
|
| Rate for Payer: Devoted Health Medicare |
$33.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.96
|
| Rate for Payer: Health Management Network Commercial |
$51.86
|
| Rate for Payer: Humana Medicare |
$30.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.50
|
| Rate for Payer: MDX Hawaii PPO |
$59.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.50
|
| Rate for Payer: University Health Alliance Commercial |
$44.47
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
NDC 70069059701
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
NDC 70069059701
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$233.86 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$280.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$233.86 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$280.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
OP
|
$198.73
|
|
|
Service Code
|
NDC 69292031715
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.36 |
| Max. Negotiated Rate |
$192.77 |
| Rate for Payer: AlohaCare Medicaid |
$99.36
|
| Rate for Payer: AlohaCare Medicare |
$99.36
|
| Rate for Payer: Cash Price |
$129.17
|
| Rate for Payer: Devoted Health Medicare |
$109.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$188.79
|
| Rate for Payer: Health Management Network Commercial |
$168.92
|
| Rate for Payer: Humana Medicare |
$99.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.36
|
| Rate for Payer: MDX Hawaii PPO |
$192.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$119.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.36
|
| Rate for Payer: University Health Alliance Commercial |
$144.85
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
IP
|
$61.01
|
|
|
Service Code
|
NDC 24208092064
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.86 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: Cash Price |
$39.66
|
| Rate for Payer: Health Management Network Commercial |
$51.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.91
|
| Rate for Payer: MDX Hawaii PPO |
$59.18
|
|
|
tetracaine 0.5% ophth drop 15 mL [HHSC]
|
Facility
|
IP
|
$198.73
|
|
|
Service Code
|
NDC 69292031715
|
| Hospital Charge Code |
2500815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$168.92 |
| Max. Negotiated Rate |
$192.77 |
| Rate for Payer: Cash Price |
$129.17
|
| Rate for Payer: Health Management Network Commercial |
$168.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.86
|
| Rate for Payer: MDX Hawaii PPO |
$192.77
|
|
|
.THC Ur Confrm FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8728220
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
.THC Ur Confrm FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8728220
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
Theophylline FSI
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
8128152
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$156.17 |
| Rate for Payer: AlohaCare Medicaid |
$80.50
|
| Rate for Payer: AlohaCare Medicare |
$80.50
|
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Devoted Health Medicare |
$88.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$19.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.14
|
| Rate for Payer: Health Management Network Commercial |
$136.85
|
| Rate for Payer: Humana Medicare |
$80.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$82.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.50
|
| Rate for Payer: MDX Hawaii PPO |
$156.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.50
|
| Rate for Payer: University Health Alliance Commercial |
$36.57
|
|
|
Theophylline FSI
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
HCPCS 80198
|
| Hospital Charge Code |
8128152
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$136.85 |
| Max. Negotiated Rate |
$156.17 |
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Health Management Network Commercial |
$136.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.90
|
| Rate for Payer: MDX Hawaii PPO |
$156.17
|
|
|
Therapeutic Activities Charge
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
HCPCS 97530 GP
|
| Hospital Charge Code |
8111693
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$260.95 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
|
|
Therapeutic Activities Charge
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
HCPCS 97530 GP
|
| Hospital Charge Code |
8111693
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: AlohaCare Medicaid |
$153.50
|
| Rate for Payer: AlohaCare Medicare |
$153.50
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Devoted Health Medicare |
$168.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.65
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Humana Medicare |
$153.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$156.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.50
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.50
|
| Rate for Payer: University Health Alliance Commercial |
$223.77
|
|
|
Therapeutic Activities Charges
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
HCPCS 97530 GP,CQ
|
| Hospital Charge Code |
8123836
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: AlohaCare Medicaid |
$123.00
|
| Rate for Payer: AlohaCare Medicare |
$123.00
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Devoted Health Medicare |
$135.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$123.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$233.70
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: Humana Medicare |
$123.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$221.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$125.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.00
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$123.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$123.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$123.00
|
| Rate for Payer: University Health Alliance Commercial |
$179.31
|
|
|
Therapeutic Activities Charges
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
HCPCS 97530 GP,CQ
|
| Hospital Charge Code |
8123836
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$209.10 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$221.40
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
|
|
Therapeutic Exercise Charges
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS 97110 GP
|
| Hospital Charge Code |
8111702
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
|
|
Therapeutic Exercise Charges
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS 97110 GP,CQ
|
| Hospital Charge Code |
8123834
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
|
