|
Bill Only M tb Direct Probe Fee
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
HCPCS 87555
|
| Hospital Charge Code |
8301500
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$223.10 |
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Health Management Network Commercial |
$195.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$207.00
|
| Rate for Payer: MDX Hawaii PPO |
$223.10
|
|
|
Bill Only Org ID Mchelonae Abc
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS 87150
|
| Hospital Charge Code |
8301472
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$354.05 |
| Rate for Payer: AlohaCare Medicaid |
$182.50
|
| Rate for Payer: AlohaCare Medicare |
$182.50
|
| Rate for Payer: Cash Price |
$237.25
|
| Rate for Payer: Cash Price |
$237.25
|
| Rate for Payer: Devoted Health Medicare |
$200.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$182.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$310.25
|
| Rate for Payer: Humana Medicare |
$182.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$328.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$186.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$182.50
|
| Rate for Payer: MDX Hawaii PPO |
$354.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$182.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$182.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$182.50
|
| Rate for Payer: University Health Alliance Commercial |
$91.37
|
|
|
Bill Only Org ID Mchelonae Abc
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS 87150
|
| Hospital Charge Code |
8301472
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$310.25 |
| Max. Negotiated Rate |
$354.05 |
| Rate for Payer: Cash Price |
$237.25
|
| Rate for Payer: Health Management Network Commercial |
$310.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$328.50
|
| Rate for Payer: MDX Hawaii PPO |
$354.05
|
|
|
Bill Only ORG IDX2
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301493
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
Bill Only ORG IDX2
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301493
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicare |
$59.50
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$65.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.08
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Humana Medicare |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.50
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.50
|
| Rate for Payer: University Health Alliance Commercial |
$20.89
|
|
|
Bill Only ORG IDX3
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301494
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicare |
$59.50
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$65.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.08
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Humana Medicare |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.50
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.50
|
| Rate for Payer: University Health Alliance Commercial |
$20.89
|
|
|
Bill Only ORG IDX3
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301494
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
Bill Only ORG IDX4
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301495
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
Bill Only ORG IDX4
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 87077
|
| Hospital Charge Code |
8301495
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicare |
$59.50
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Cash Price |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$65.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.08
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Humana Medicare |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.50
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.50
|
| Rate for Payer: University Health Alliance Commercial |
$20.89
|
|
|
Bill Only Pap Smear Gyn
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS 88164
|
| Hospital Charge Code |
8409271
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: AlohaCare Medicaid |
$68.00
|
| Rate for Payer: AlohaCare Medicare |
$68.00
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Devoted Health Medicare |
$74.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$14.60
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.54
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Humana Medicare |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.00
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.00
|
| Rate for Payer: University Health Alliance Commercial |
$27.31
|
|
|
Bill Only Pap Smear Gyn
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS 88164
|
| Hospital Charge Code |
8409271
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$115.60 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: Cash Price |
$88.40
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
|
|
Bill Only Phlebotomy
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
8301488
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
Bill Only Phlebotomy
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 36415
|
| Hospital Charge Code |
8301488
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.00 |
| 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 Commercial |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| 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 |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.00
|
| Rate for Payer: University Health Alliance Commercial |
$36.96
|
|
|
Bill Only PLT Neut
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
8301503
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
|
|
Bill Only PLT Neut
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS 85597
|
| Hospital Charge Code |
8301503
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$17.98 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: AlohaCare Medicaid |
$83.00
|
| Rate for Payer: AlohaCare Medicare |
$83.00
|
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Devoted Health Medicare |
$91.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.98
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Humana Medicare |
$83.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.00
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.00
|
| Rate for Payer: University Health Alliance Commercial |
$46.47
|
|
|
Bill Only PTT Mix
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 85732
|
| Hospital Charge Code |
8301504
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$34.50
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Devoted Health Medicare |
$37.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.47
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$34.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.50
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.50
|
| Rate for Payer: University Health Alliance Commercial |
$16.72
|
|
|
Bill Only PTT Mix
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 85732
|
| Hospital Charge Code |
8301504
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
|
|
Bill Only Reptilase Time
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS 85635
|
| Hospital Charge Code |
8301485
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: AlohaCare Medicaid |
$48.00
|
| Rate for Payer: AlohaCare Medicare |
$48.00
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Devoted Health Medicare |
$52.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.85
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Humana Medicare |
$48.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.00
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.00
|
| Rate for Payer: University Health Alliance Commercial |
$25.46
|
|
|
Bill Only Reptilase Time
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS 85635
|
| Hospital Charge Code |
8301485
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.40
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
|
|
Bill Only Sensitivity Mic KSO FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
8453178
|
|
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
|
|
|
Bill Only Sensitivity Mic KSO FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
8453178
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.65 |
| 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 |
$11.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.65
|
| 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 |
$11.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.35
|
|
|
Bill Only SINGL AG AB ID CII LMX
|
Facility
|
IP
|
$1,085.00
|
|
|
Service Code
|
HCPCS 86833
|
| Hospital Charge Code |
8301502
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$922.25 |
| Max. Negotiated Rate |
$1,052.45 |
| Rate for Payer: Cash Price |
$705.25
|
| Rate for Payer: Health Management Network Commercial |
$922.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$976.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,052.45
|
|
|
Bill Only SINGL AG AB ID CII LMX
|
Facility
|
OP
|
$1,085.00
|
|
|
Service Code
|
HCPCS 86833
|
| Hospital Charge Code |
8301502
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$95.13 |
| Max. Negotiated Rate |
$1,052.45 |
| Rate for Payer: AlohaCare Medicaid |
$542.50
|
| Rate for Payer: AlohaCare Medicare |
$542.50
|
| Rate for Payer: Cash Price |
$705.25
|
| Rate for Payer: Cash Price |
$705.25
|
| Rate for Payer: Devoted Health Medicare |
$596.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$407.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$542.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$167.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$325.80
|
| Rate for Payer: Health Management Network Commercial |
$922.25
|
| Rate for Payer: Humana Medicare |
$542.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$976.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$553.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$542.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,052.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$542.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$542.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$95.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$542.50
|
| Rate for Payer: University Health Alliance Commercial |
$607.60
|
|
|
Bill Only SINGLE AG AB ID CI LMX
|
Facility
|
OP
|
$1,194.00
|
|
|
Service Code
|
HCPCS 86832
|
| Hospital Charge Code |
8301501
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$104.64 |
| Max. Negotiated Rate |
$1,158.18 |
| Rate for Payer: AlohaCare Medicaid |
$597.00
|
| Rate for Payer: AlohaCare Medicare |
$597.00
|
| Rate for Payer: Cash Price |
$776.10
|
| Rate for Payer: Cash Price |
$776.10
|
| Rate for Payer: Devoted Health Medicare |
$656.70
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$404.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$597.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$184.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$323.75
|
| Rate for Payer: Health Management Network Commercial |
$1,014.90
|
| Rate for Payer: Humana Medicare |
$597.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,074.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$608.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$597.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,158.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$597.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$597.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$597.00
|
| Rate for Payer: University Health Alliance Commercial |
$322.64
|
|
|
Bill Only SINGLE AG AB ID CI LMX
|
Facility
|
IP
|
$1,194.00
|
|
|
Service Code
|
HCPCS 86832
|
| Hospital Charge Code |
8301501
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1,014.90 |
| Max. Negotiated Rate |
$1,158.18 |
| Rate for Payer: Cash Price |
$776.10
|
| Rate for Payer: Health Management Network Commercial |
$1,014.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,074.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,158.18
|
|
