|
Therapeutic Exercise Charges
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS 97110 GP
|
| Hospital Charge Code |
8111702
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: AlohaCare Medicaid |
$99.50
|
| Rate for Payer: AlohaCare Medicare |
$99.50
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Devoted Health Medicare |
$109.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$189.05
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Humana Medicare |
$99.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.50
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.50
|
| Rate for Payer: University Health Alliance Commercial |
$145.05
|
|
|
Therapeutic Exercise Charges
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS 97110 GP,CQ
|
| Hospital Charge Code |
8123834
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: AlohaCare Medicaid |
$99.50
|
| Rate for Payer: AlohaCare Medicare |
$99.50
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Devoted Health Medicare |
$109.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$189.05
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Humana Medicare |
$99.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.50
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.50
|
| Rate for Payer: University Health Alliance Commercial |
$145.05
|
|
|
THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; FIRST 2 VERTEBRAL BODIES, LUMBAR OR SACRAL
|
Facility
|
OP
|
$16,395.95
|
|
|
Service Code
|
CPT 64628
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$16,395.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16,395.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00536468001
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904719106
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904719106
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 80681009800
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00536468001
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 80681009800
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904054460
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904054460
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 87701040729
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 87701040729
|
| Hospital Charge Code |
2500820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
thiamine 200 mg/2 ml vial [HHSC]
|
Facility
|
IP
|
$70.14
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
2500821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.62 |
| Max. Negotiated Rate |
$68.04 |
| Rate for Payer: Cash Price |
$45.59
|
| Rate for Payer: Cash Price |
$44.24
|
| Rate for Payer: Cash Price |
$40.55
|
| Rate for Payer: Health Management Network Commercial |
$53.02
|
| Rate for Payer: Health Management Network Commercial |
$59.62
|
| Rate for Payer: Health Management Network Commercial |
$57.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.14
|
| Rate for Payer: MDX Hawaii PPO |
$66.02
|
| Rate for Payer: MDX Hawaii PPO |
$60.51
|
| Rate for Payer: MDX Hawaii PPO |
$68.04
|
|
|
thiamine 200 mg/2 ml vial [HHSC]
|
Facility
|
OP
|
$62.38
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
2500821
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$60.51 |
| Rate for Payer: AlohaCare Medicaid |
$31.19
|
| Rate for Payer: AlohaCare Medicaid |
$35.07
|
| Rate for Payer: AlohaCare Medicaid |
$34.03
|
| Rate for Payer: AlohaCare Medicare |
$34.03
|
| Rate for Payer: AlohaCare Medicare |
$31.19
|
| Rate for Payer: AlohaCare Medicare |
$35.07
|
| Rate for Payer: Cash Price |
$44.24
|
| Rate for Payer: Cash Price |
$45.59
|
| Rate for Payer: Cash Price |
$44.24
|
| Rate for Payer: Cash Price |
$40.55
|
| Rate for Payer: Cash Price |
$40.55
|
| Rate for Payer: Cash Price |
$45.59
|
| Rate for Payer: Devoted Health Medicare |
$34.31
|
| Rate for Payer: Devoted Health Medicare |
$38.58
|
| Rate for Payer: Devoted Health Medicare |
$37.43
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.63
|
| Rate for Payer: Health Management Network Commercial |
$59.62
|
| Rate for Payer: Health Management Network Commercial |
$53.02
|
| Rate for Payer: Health Management Network Commercial |
$57.85
|
| Rate for Payer: Humana Medicare |
$31.19
|
| Rate for Payer: Humana Medicare |
$34.03
|
| Rate for Payer: Humana Medicare |
$35.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.07
|
| Rate for Payer: MDX Hawaii PPO |
$68.04
|
| Rate for Payer: MDX Hawaii PPO |
$66.02
|
| Rate for Payer: MDX Hawaii PPO |
$60.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.07
|
| Rate for Payer: University Health Alliance Commercial |
$45.47
|
| Rate for Payer: University Health Alliance Commercial |
$49.61
|
| Rate for Payer: University Health Alliance Commercial |
$51.13
|
|
|
Thiamine (Vitamin B1) Whole Blood FSI
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
8228924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
Thiamine (Vitamin B1) Whole Blood FSI
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
8228924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.23 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicare |
$54.50
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Devoted Health Medicare |
$59.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.36
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.23
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Humana Medicare |
$54.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.50
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.50
|
| Rate for Payer: University Health Alliance Commercial |
$49.30
|
|
|
Throat Culture FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8118057
|
|
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
|
|
|
Throat Culture FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8118057
|
|
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
|
|
|
thrombin 5000 unit powder topical [HHSC]
|
Facility
|
IP
|
$372.87
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
2500823
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.94 |
| Max. Negotiated Rate |
$361.68 |
| Rate for Payer: Cash Price |
$242.37
|
| Rate for Payer: Health Management Network Commercial |
$316.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$335.58
|
| Rate for Payer: MDX Hawaii PPO |
$361.68
|
|
|
thrombin 5000 unit powder topical [HHSC]
|
Facility
|
OP
|
$372.87
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
2500823
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.44 |
| Max. Negotiated Rate |
$361.68 |
| Rate for Payer: AlohaCare Medicaid |
$186.44
|
| Rate for Payer: AlohaCare Medicare |
$186.44
|
| Rate for Payer: Cash Price |
$242.37
|
| Rate for Payer: Devoted Health Medicare |
$205.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$354.23
|
| Rate for Payer: Health Management Network Commercial |
$316.94
|
| Rate for Payer: Humana Medicare |
$186.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$335.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$190.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.44
|
| Rate for Payer: MDX Hawaii PPO |
$361.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$223.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.44
|
| Rate for Payer: University Health Alliance Commercial |
$271.78
|
|
|
Thrombin Time Bill only
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
12514693
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
Thrombin Time Bill only
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
12514693
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicare |
$33.00
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Devoted Health Medicare |
$36.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.77
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$33.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.00
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.00
|
| Rate for Payer: University Health Alliance Commercial |
$14.93
|
|
