|
99492 1st Psychiatric Collab Care Mgmt 1st 70 Min
|
Professional
|
Both
|
$303.00
|
|
|
Service Code
|
HCPCS 99492
|
| Hospital Charge Code |
11404762
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$82.21 |
| Max. Negotiated Rate |
$257.55 |
| Rate for Payer: AlohaCare Medicaid |
$95.04
|
| Rate for Payer: AlohaCare Medicare |
$82.21
|
| Rate for Payer: Cash Price |
$196.95
|
| Rate for Payer: Cash Price |
$196.95
|
| Rate for Payer: Devoted Health Medicare |
$90.43
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$95.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$95.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$173.83
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$95.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.21
|
| Rate for Payer: University Health Alliance Commercial |
$112.69
|
|
|
99493 Sbsq Psychiatric Collab Care Mgmt 1st 60 Min
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 99493
|
| Hospital Charge Code |
11415546
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$89.79 |
| Max. Negotiated Rate |
$195.50 |
| Rate for Payer: AlohaCare Medicaid |
$103.75
|
| Rate for Payer: AlohaCare Medicare |
$89.79
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Devoted Health Medicare |
$98.77
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$103.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$103.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.78
|
| Rate for Payer: Health Management Network Commercial |
$195.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$103.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.79
|
| Rate for Payer: University Health Alliance Commercial |
$123.99
|
|
|
99494 1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 99494
|
| Hospital Charge Code |
11414883
|
|
Hospital Revenue Code
|
961
|
| Min. Negotiated Rate |
$78.20 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
|
|
99494 1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 99494
|
| Hospital Charge Code |
11414883
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$36.14 |
| Max. Negotiated Rate |
$97.75 |
| Rate for Payer: AlohaCare Medicaid |
$41.62
|
| Rate for Payer: AlohaCare Medicare |
$36.14
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Devoted Health Medicare |
$39.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$41.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$41.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.09
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.14
|
| Rate for Payer: University Health Alliance Commercial |
$50.66
|
|
|
99494 1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 99494
|
| Hospital Charge Code |
11414883
|
|
Hospital Revenue Code
|
961
|
| Min. Negotiated Rate |
$41.62 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: AlohaCare Medicaid |
$46.00
|
| Rate for Payer: AlohaCare Medicare |
$46.00
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Devoted Health Medicare |
$50.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.40
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Humana Medicare |
$46.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.00
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.00
|
| Rate for Payer: University Health Alliance Commercial |
$51.52
|
|
|
99497 Advance Care Planning, First 30 Minutes
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 99497
|
| Hospital Charge Code |
8041148
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$76.28
|
| Rate for Payer: AlohaCare Medicare |
$66.27
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Devoted Health Medicare |
$72.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| 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 |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| 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: Hawaii Western Management Group Commercial |
$90.40
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| 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 Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.27
|
| 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 |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
|
|
ABO Group FSI
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS 86900
|
| Hospital Charge Code |
8117758
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicare |
$47.00
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Devoted Health Medicare |
$51.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.99
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Humana Medicare |
$47.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.00
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.00
|
| Rate for Payer: University Health Alliance Commercial |
$7.71
|
|
|
ABO Group FSI
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS 86900
|
| Hospital Charge Code |
8117758
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.90 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$61.10
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
|
|
ABO RH Antibody Screen (Not XM Convertible) FSI
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS 86850
|
| Hospital Charge Code |
8117759
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: AlohaCare Medicaid |
$80.00
|
| Rate for Payer: AlohaCare Medicare |
$80.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Devoted Health Medicare |
$88.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$19.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.77
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Humana Medicare |
$80.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.00
|
| Rate for Payer: University Health Alliance Commercial |
$50.88
|
|
|
ABO RH Antibody Screen (Not XM Convertible) FSI
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS 86850
|
| Hospital Charge Code |
8117759
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$10,760.71
|
|
|
Service Code
|
MSDRG 770
|
| Min. Negotiated Rate |
$10,760.71 |
| Max. Negotiated Rate |
$10,760.71 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,760.71
|
|
|
ABORTION WITHOUT D&C
|
Facility
|
IP
|
$7,347.62
|
|
|
Service Code
|
MSDRG 779
|
| Min. Negotiated Rate |
$7,347.62 |
| Max. Negotiated Rate |
$7,347.62 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,347.62
|
|
|
Abscess Culture with Gram stain
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12516235
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: AlohaCare Medicaid |
$53.50
|
| Rate for Payer: AlohaCare Medicare |
$53.50
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Devoted Health Medicare |
$58.85
|
| 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 |
$53.50
|
| 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 |
$90.95
|
| Rate for Payer: Humana Medicare |
$53.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.50
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Abscess Culture with Gram stain
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12516235
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
Abscess Culture with Gram stain bill only
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12539009
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: AlohaCare Medicaid |
$53.50
|
| Rate for Payer: AlohaCare Medicare |
$53.50
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Devoted Health Medicare |
$58.85
|
| 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 |
$53.50
|
| 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 |
$90.95
|
| Rate for Payer: Humana Medicare |
$53.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.50
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Abscess Culture with Gram stain bill only
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12539009
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
Abscess Culture with Gram stain - Bill only
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12514773
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: AlohaCare Medicaid |
$53.50
|
| Rate for Payer: AlohaCare Medicare |
$53.50
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Devoted Health Medicare |
$58.85
|
| 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 |
$53.50
|
| 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 |
$90.95
|
| Rate for Payer: Humana Medicare |
$53.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.50
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Abscess Culture with Gram stain - Bill only
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
12514773
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
ABSORBATACK FIXATION DEVICE
|
Facility
|
IP
|
$2,456.00
|
|
| Hospital Charge Code |
10109437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,087.60 |
| Max. Negotiated Rate |
$2,382.32 |
| Rate for Payer: Cash Price |
$1,596.40
|
| Rate for Payer: Health Management Network Commercial |
$2,087.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,210.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,382.32
|
|
|
ABSORBATACK FIXATION DEVICE
|
Facility
|
OP
|
$2,456.00
|
|
| Hospital Charge Code |
10109437
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,228.00 |
| Max. Negotiated Rate |
$2,382.32 |
| Rate for Payer: AlohaCare Medicaid |
$1,228.00
|
| Rate for Payer: AlohaCare Medicare |
$1,228.00
|
| Rate for Payer: Cash Price |
$1,596.40
|
| Rate for Payer: Devoted Health Medicare |
$1,350.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,228.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,333.20
|
| Rate for Payer: Health Management Network Commercial |
$2,087.60
|
| Rate for Payer: Humana Medicare |
$1,228.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,210.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,252.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,228.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,382.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,228.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,228.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,228.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,790.18
|
|
|
acetaminophen 1000 mg/100 mL injection [HHSC]
|
Facility
|
OP
|
$57.89
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
2501174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$56.15 |
| Rate for Payer: AlohaCare Medicaid |
$28.95
|
| Rate for Payer: AlohaCare Medicaid |
$36.28
|
| Rate for Payer: AlohaCare Medicaid |
$101.89
|
| Rate for Payer: AlohaCare Medicare |
$36.28
|
| Rate for Payer: AlohaCare Medicare |
$101.89
|
| Rate for Payer: AlohaCare Medicare |
$28.95
|
| Rate for Payer: Cash Price |
$132.46
|
| Rate for Payer: Cash Price |
$47.17
|
| Rate for Payer: Cash Price |
$132.46
|
| Rate for Payer: Cash Price |
$47.17
|
| Rate for Payer: Cash Price |
$37.63
|
| Rate for Payer: Cash Price |
$37.63
|
| Rate for Payer: Devoted Health Medicare |
$39.91
|
| Rate for Payer: Devoted Health Medicare |
$31.84
|
| Rate for Payer: Devoted Health Medicare |
$112.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$101.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$68.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$193.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.00
|
| Rate for Payer: Health Management Network Commercial |
$173.21
|
| Rate for Payer: Health Management Network Commercial |
$49.21
|
| Rate for Payer: Health Management Network Commercial |
$61.68
|
| Rate for Payer: Humana Medicare |
$28.95
|
| Rate for Payer: Humana Medicare |
$101.89
|
| Rate for Payer: Humana Medicare |
$36.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$101.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.28
|
| Rate for Payer: MDX Hawaii PPO |
$70.39
|
| Rate for Payer: MDX Hawaii PPO |
$197.67
|
| Rate for Payer: MDX Hawaii PPO |
$56.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$101.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$101.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$101.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.95
|
| Rate for Payer: University Health Alliance Commercial |
$52.90
|
| Rate for Payer: University Health Alliance Commercial |
$42.20
|
| Rate for Payer: University Health Alliance Commercial |
$148.54
|
|
|
acetaminophen 1000 mg/100 mL injection [HHSC]
|
Facility
|
IP
|
$57.89
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
2501174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.21 |
| Max. Negotiated Rate |
$56.15 |
| Rate for Payer: Cash Price |
$37.63
|
| Rate for Payer: Cash Price |
$132.46
|
| Rate for Payer: Cash Price |
$47.17
|
| Rate for Payer: Health Management Network Commercial |
$61.68
|
| Rate for Payer: Health Management Network Commercial |
$173.21
|
| Rate for Payer: Health Management Network Commercial |
$49.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.10
|
| Rate for Payer: MDX Hawaii PPO |
$56.15
|
| Rate for Payer: MDX Hawaii PPO |
$197.67
|
| Rate for Payer: MDX Hawaii PPO |
$70.39
|
|
|
acetaminophen 120 mg suppository [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802073233
|
| Hospital Charge Code |
2500001
|
|
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
|
|
|
acetaminophen 120 mg suppository [HHSC]
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 51672211502
|
| Hospital Charge Code |
2500001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Health Management Network Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.01
|
| Rate for Payer: MDX Hawaii PPO |
$4.33
|
|
|
acetaminophen 120 mg suppository [HHSC]
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 51672211502
|
| Hospital Charge Code |
2500001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: AlohaCare Medicaid |
$2.23
|
| Rate for Payer: AlohaCare Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Devoted Health Medicare |
$2.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.24
|
| Rate for Payer: Health Management Network Commercial |
$3.79
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$4.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$3.25
|
|
