|
96375-IV Push Each Additional New Drug
|
Facility
|
OP
|
$325.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
8079983
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$162.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$162.50
|
| Rate for Payer: AlohaCare Medicare |
$162.50
|
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Devoted Health Medicare |
$178.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$162.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$308.75
|
| Rate for Payer: Health Management Network Commercial |
$276.25
|
| Rate for Payer: Humana Medicare |
$162.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$292.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$162.50
|
| Rate for Payer: MDX Hawaii PPO |
$315.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$162.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$162.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$162.50
|
| Rate for Payer: University Health Alliance Commercial |
$236.89
|
|
|
96375-IV Push Each Additional New Drug
|
Facility
|
IP
|
$325.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
8079983
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$276.25 |
| Max. Negotiated Rate |
$315.25 |
| Rate for Payer: Cash Price |
$211.25
|
| Rate for Payer: Health Management Network Commercial |
$276.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$292.50
|
| Rate for Payer: MDX Hawaii PPO |
$315.25
|
|
|
96375 Therapeutic, prophylactic, or diagnostic injection (specify
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
9143831
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$10.14
|
| Rate for Payer: AlohaCare Medicare |
$17.21
|
| Rate for Payer: Cash Price |
$42.25
|
| Rate for Payer: Cash Price |
$42.25
|
| Rate for Payer: Cash Price |
$42.25
|
| Rate for Payer: Devoted Health Medicare |
$18.93
|
| 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 |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| 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 |
$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 |
$26.44
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.65
|
| 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 |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| 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: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| 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 |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
96376- ED IV Injection, add same drug
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
1928307
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$128.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$128.50
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Devoted Health Medicare |
$141.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$128.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.50
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.50
|
| Rate for Payer: University Health Alliance Commercial |
$187.33
|
|
|
96376- ED IV Injection, add same drug
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
1928307
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
96376 IV Push Addl Same Drug > 30Min Charge
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
8220034
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$128.50 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$128.50
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Devoted Health Medicare |
$141.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$128.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.50
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.50
|
| Rate for Payer: University Health Alliance Commercial |
$143.92
|
|
|
96376 IV Push Addl Same Drug > 30Min Charge
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
8220034
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
96376-IV Push Addl Same Drug Greater Than 30 mins
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
8079985
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$128.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$128.50
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Devoted Health Medicare |
$141.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$128.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.50
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.50
|
| Rate for Payer: University Health Alliance Commercial |
$187.33
|
|
|
96376-IV Push Addl Same Drug Greater Than 30 mins
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
8079985
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
96379 Unlisted IV Inj or Inf Charge
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 96379
|
| Hospital Charge Code |
8220037
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$252.20 |
| Rate for Payer: AlohaCare Medicaid |
$130.00
|
| Rate for Payer: AlohaCare Medicare |
$130.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Devoted Health Medicare |
$143.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$130.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$247.00
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Humana Medicare |
$130.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$132.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$130.00
|
| Rate for Payer: MDX Hawaii PPO |
$252.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$130.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$130.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$130.00
|
| Rate for Payer: University Health Alliance Commercial |
$145.60
|
|
|
96379 Unlisted IV Inj or Inf Charge
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
HCPCS 96379
|
| Hospital Charge Code |
8220037
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$252.20 |
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.00
|
| Rate for Payer: MDX Hawaii PPO |
$252.20
|
|
|
96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12351125
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$73.50
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Devoted Health Medicare |
$80.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$73.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.50
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.50
|
| Rate for Payer: University Health Alliance Commercial |
$82.32
|
|
|
96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12351125
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
96380 Adminstration of Beyfortus w/counseling
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12114523
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
96380 Adminstration of Beyfortus w/counseling
|
Professional
|
Both
|
$142.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12114523
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$120.70 |
| Rate for Payer: AlohaCare Medicaid |
$14.77
|
| Rate for Payer: AlohaCare Medicare |
$32.53
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$35.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.53
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.53
|
|
|
96380 Adminstration of Beyfortus w/counseling
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12114523
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$73.50
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Devoted Health Medicare |
$80.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$73.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.50
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.50
|
| Rate for Payer: University Health Alliance Commercial |
$82.32
|
|
|
96380 VFC Adminstration of Beyfortus w/counseling
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12124363
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: AlohaCare Medicaid |
$14.77
|
| Rate for Payer: AlohaCare Medicare |
$32.53
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$35.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.53
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.53
|
|
|
96380 VFC Adminstration of Beyfortus w/counseling
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12124363
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
96380 VFC Adminstration of Beyfortus w/counseling
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
12124363
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$14.00
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Devoted Health Medicare |
$15.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$14.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.00
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.00
|
| Rate for Payer: University Health Alliance Commercial |
$15.68
|
|
|
96381 Administration of Beyfortus w/o counseling
|
Professional
|
Both
|
$142.00
|
|
|
Service Code
|
HCPCS 96381
|
| Hospital Charge Code |
12114524
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$120.70 |
| Rate for Payer: AlohaCare Medicaid |
$12.92
|
| Rate for Payer: AlohaCare Medicare |
$26.76
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$29.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.76
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.76
|
|
|
96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 96381
|
| Hospital Charge Code |
12351126
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 96381
|
| Hospital Charge Code |
12351126
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$60.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Devoted Health Medicare |
$66.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$60.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.00
|
| Rate for Payer: University Health Alliance Commercial |
$67.20
|
|
|
96381 VFC Administration of Beyfortus w/o counseling
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
HCPCS 96381
|
| Hospital Charge Code |
12124364
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$32.11 |
| Rate for Payer: AlohaCare Medicaid |
$12.92
|
| Rate for Payer: AlohaCare Medicare |
$26.76
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Devoted Health Medicare |
$29.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.76
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.76
|
|
|
96521 REFILL MAINT PORTABLE PUMP CHARGE
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
8221510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.13 |
| Max. Negotiated Rate |
$838.08 |
| Rate for Payer: AlohaCare Medicaid |
$432.00
|
| Rate for Payer: AlohaCare Medicare |
$432.00
|
| Rate for Payer: Cash Price |
$561.60
|
| Rate for Payer: Cash Price |
$561.60
|
| Rate for Payer: Devoted Health Medicare |
$475.20
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$271.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$432.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$820.80
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Humana Medicare |
$432.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$440.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$432.00
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$432.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$432.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$432.00
|
| Rate for Payer: University Health Alliance Commercial |
$483.84
|
|
|
96521 REFILL MAINT PORTABLE PUMP CHARGE
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
8221510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$734.40 |
| Max. Negotiated Rate |
$838.08 |
| Rate for Payer: Cash Price |
$561.60
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
|
