|
90713 Poliovirus vaccine, inactivated (IPV)
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
8041229
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.41
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90714 Tenivac - Tetanus and diphtheria toxoids (Td), over 18
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
8041230
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: AlohaCare Medicare |
$38.75
|
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Devoted Health Medicare |
$42.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.25
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.75
|
|
|
90715 PH Tdap, when administered to individuals 7 years or older, for intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
8050254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$47.38 |
| Rate for Payer: AlohaCare Medicare |
$39.48
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Devoted Health Medicare |
$43.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.89
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.48
|
|
|
90715 Tdap, when administered to individuals 7 years or older, for intramuscular use
|
Professional
|
Both
|
$111.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
8041231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$94.35 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$39.48
|
| Rate for Payer: Cash Price |
$72.15
|
| Rate for Payer: Cash Price |
$72.15
|
| Rate for Payer: Devoted Health Medicare |
$43.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.89
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.48
|
|
|
90716 PH Varicella virus vaccine, live, for subcutaneous use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
8050255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$131.65 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.65
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90716 Varicella virus vaccine, live, for subcutaneous use
|
Professional
|
Both
|
$233.00
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
8041232
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$198.05 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$151.45
|
| Rate for Payer: Cash Price |
$151.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.65
|
| Rate for Payer: Health Management Network Commercial |
$198.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90723 PH DTaP-HepB-IPV (Pediarix), for intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
8050256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$82.43 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.43
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90732 PH Pneumococcal polysaccharide vaccine, 23-valent, for subcutaneous or intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
8084413
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$160.16 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$133.47
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Devoted Health Medicare |
$146.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$133.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.45
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$160.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$133.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$133.47
|
|
|
90732 Pneumococcal polysaccharide vaccine, 23-valent, for subcutaneous or intramuscular use
|
Professional
|
Both
|
$155.00
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
8041235
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$160.16 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$133.47
|
| Rate for Payer: Cash Price |
$100.75
|
| Rate for Payer: Cash Price |
$100.75
|
| Rate for Payer: Devoted Health Medicare |
$146.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$133.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.45
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$160.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$133.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$133.47
|
|
|
90734 Meningococcal conjugate vaccine, quadrivalent, for intramuscular use
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
8041237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$259.25 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$198.25
|
| Rate for Payer: Cash Price |
$198.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90734 Meningococcal (Menveo) conjugate vaccine, quadrivalent, for intramuscular use
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
9486141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$348.50 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$348.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90734 Meningococcal (Menveo) conjugate vaccine, quadrivalent, for intramuscular use HHSC
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
10399135
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$348.50 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$348.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90734 PH Meningococcal conjugate vaccine, quadrivalent, for intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
8050257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$125.47 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90734 VFC Meningococcal (Menveo) conjugate vaccine, quadrivalent, for intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
9486142
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$125.47 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90734 VFC Meningococcal (Menveo) conjugate vaccine, quadrivalent, for intramuscular use HHSC
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
10399130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$125.47 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.47
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
|
|
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
8041241
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Devoted Health Medicare |
$36.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.77
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.20
|
|
|
90744 PH Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
8050259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$39.84 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$33.20
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Devoted Health Medicare |
$36.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.77
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.20
|
|
|
90746 Vaccine - Hepatitis B Adult Vaccine
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
HCPCS 90746
|
| Hospital Charge Code |
8041242
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$130.90 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$75.15
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Devoted Health Medicare |
$82.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.64
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$90.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.15
|
|
|
90747 Hepatitis B Vaccine Dialysis or Immunosuppressed 4 Dose IM
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
HCPCS 90747
|
| Hospital Charge Code |
8046245
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$414.80 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$164.42
|
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Devoted Health Medicare |
$180.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$164.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.50
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$197.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$197.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$197.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$164.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$164.42
|
|
|
90785 Interactive complexity
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
HCPCS 90785
|
| Hospital Charge Code |
8040962
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$13.08
|
| Rate for Payer: AlohaCare Medicare |
$11.78
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Devoted Health Medicare |
$12.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$14.19
|
|
|
90791 Psychiatric diagnostic evaluation
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS G0444
|
| Hospital Charge Code |
11287822
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$9.24
|
| Rate for Payer: AlohaCare Medicare |
$8.10
|
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Cash Price |
$20.15
|
| Rate for Payer: Devoted Health Medicare |
$8.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.72
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: University Health Alliance Commercial |
$8.98
|
|
|
90791 Psychiatric diagnostic evaluation - no medical services Charge
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 90791
|
| Hospital Charge Code |
8539593
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$138.14 |
| Max. Negotiated Rate |
$382.50 |
| Rate for Payer: AlohaCare Medicaid |
$148.43
|
| Rate for Payer: AlohaCare Medicare |
$138.14
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Devoted Health Medicare |
$151.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$148.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$138.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$148.43
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$165.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$148.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$138.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$148.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$138.14
|
| Rate for Payer: University Health Alliance Commercial |
$179.86
|
|
|
90791 Psychiatric diagnostic evaluation - no medical services Charge
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 90791
|
| Hospital Charge Code |
8539593
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$104.43 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$225.00
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Devoted Health Medicare |
$247.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$226.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$225.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$225.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$225.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$225.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$225.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$225.00
|
| Rate for Payer: University Health Alliance Commercial |
$252.00
|
|
|
90791 Psychiatric diagnostic evaluation - no medical services Charge
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 90791
|
| Hospital Charge Code |
8539593
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
|
|
90792 Psychiatric diagnostic Evaluation - with medical services Charge
|
Facility
|
IP
|
$1,101.00
|
|
|
Service Code
|
HCPCS 90792
|
| Hospital Charge Code |
8540239
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$935.85 |
| Max. Negotiated Rate |
$1,067.97 |
| Rate for Payer: Cash Price |
$715.65
|
| Rate for Payer: Health Management Network Commercial |
$935.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$990.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,067.97
|
|
