|
Fentanyl Quant Urine FSI
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 80354
|
| Hospital Charge Code |
8686247
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Health Management Network Commercial |
$255.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.00
|
| Rate for Payer: MDX Hawaii PPO |
$291.00
|
|
|
Fentanyl Quant Urine FSI
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 80354
|
| Hospital Charge Code |
8686247
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.89 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: AlohaCare Medicaid |
$150.00
|
| Rate for Payer: AlohaCare Medicare |
$150.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Devoted Health Medicare |
$165.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$150.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$285.00
|
| Rate for Payer: Health Management Network Commercial |
$255.00
|
| Rate for Payer: Humana Medicare |
$150.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$150.00
|
| Rate for Payer: MDX Hawaii PPO |
$291.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$150.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$150.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$150.00
|
| Rate for Payer: University Health Alliance Commercial |
$168.00
|
|
|
Ferritin FSI
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
8117909
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicare |
$61.50
|
| Rate for Payer: Cash Price |
$79.95
|
| Rate for Payer: Cash Price |
$79.95
|
| Rate for Payer: Devoted Health Medicare |
$67.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.81
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.63
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Humana Medicare |
$61.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.50
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.50
|
| Rate for Payer: University Health Alliance Commercial |
$29.56
|
|
|
Ferritin FSI
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
8117909
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: Cash Price |
$79.95
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
|
|
ferrous sulfate 324 mg EC tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00574060811
|
| Hospital Charge Code |
2500324
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ferrous sulfate 324 mg EC tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00574060811
|
| Hospital Charge Code |
2500324
|
|
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
|
|
|
Fetal biophysical profile, without non-stress test
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
8102222
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$46.56 |
| Max. Negotiated Rate |
$195.62 |
| Rate for Payer: AlohaCare Medicaid |
$72.50
|
| Rate for Payer: AlohaCare Medicare |
$72.50
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Devoted Health Medicare |
$79.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$46.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$133.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$58.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.81
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Humana Medicare |
$72.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.50
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.50
|
| Rate for Payer: University Health Alliance Commercial |
$195.62
|
|
|
Fetal biophysical profile, without non-stress test
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
8102222
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
|
|
Fetal biophysical profile, without non-stress test
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
8102222
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$56.22 |
| Max. Negotiated Rate |
$146.20 |
| Rate for Payer: AlohaCare Medicaid |
$56.22
|
| Rate for Payer: AlohaCare Medicare |
$95.33
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$104.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.03
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.33
|
|
|
Fetal Contraction Stress Test
|
Facility
|
IP
|
$440.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
8141336
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$374.00 |
| Max. Negotiated Rate |
$426.80 |
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Health Management Network Commercial |
$374.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$396.00
|
| Rate for Payer: MDX Hawaii PPO |
$426.80
|
|
|
Fetal Contraction Stress Test
|
Facility
|
OP
|
$440.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
8141336
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$426.80 |
| Rate for Payer: AlohaCare Medicaid |
$220.00
|
| Rate for Payer: AlohaCare Medicare |
$220.00
|
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Devoted Health Medicare |
$242.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$53.69
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$258.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$220.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$418.00
|
| Rate for Payer: Health Management Network Commercial |
$374.00
|
| Rate for Payer: Humana Medicare |
$220.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$396.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$224.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$220.00
|
| Rate for Payer: MDX Hawaii PPO |
$426.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$220.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$220.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$220.00
|
| Rate for Payer: University Health Alliance Commercial |
$246.40
|
|
|
Fetal Contraction Stress Test
|
Facility
|
OP
|
$440.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
8141335
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$426.80 |
| Rate for Payer: AlohaCare Medicaid |
$220.00
|
| Rate for Payer: AlohaCare Medicare |
$220.00
|
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Devoted Health Medicare |
$242.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$53.69
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$258.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$220.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$418.00
|
| Rate for Payer: Health Management Network Commercial |
$374.00
|
| Rate for Payer: Humana Medicare |
$220.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$396.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$224.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$220.00
|
| Rate for Payer: MDX Hawaii PPO |
$426.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$220.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$220.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$220.00
|
| Rate for Payer: University Health Alliance Commercial |
$246.40
|
|
|
Fetal Contraction Stress Test
|
Facility
|
IP
|
$440.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
8141335
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$374.00 |
| Max. Negotiated Rate |
$426.80 |
| Rate for Payer: Cash Price |
$286.00
|
| Rate for Payer: Health Management Network Commercial |
$374.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$396.00
|
| Rate for Payer: MDX Hawaii PPO |
$426.80
|
|
|
Fetal Fibronectin Screen FSI
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
8117910
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Health Management Network Commercial |
$765.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$810.00
|
| Rate for Payer: MDX Hawaii PPO |
$873.00
|
|
|
Fetal Fibronectin Screen FSI
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
8117910
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$64.41 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: AlohaCare Medicaid |
$450.00
|
| Rate for Payer: AlohaCare Medicare |
$450.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Devoted Health Medicare |
$495.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$89.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$239.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.41
|
| Rate for Payer: Health Management Network Commercial |
$765.00
|
| Rate for Payer: Humana Medicare |
$450.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$810.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$459.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.00
|
| Rate for Payer: MDX Hawaii PPO |
$873.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$450.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$450.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.00
|
| Rate for Payer: University Health Alliance Commercial |
$166.48
|
|
|
Fetal Non-Stress Test
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
8074276
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$723.35 |
| Rate for Payer: AlohaCare Medicaid |
$51.24
|
| Rate for Payer: AlohaCare Medicare |
$52.36
|
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Devoted Health Medicare |
$57.60
|
| 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 |
$44.98
|
| Rate for Payer: Health Management Network Commercial |
$723.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.83
|
| 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 |
$51.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.36
|
| 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
|
|
|
Fetal Non-Stress Test
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
8074275
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$825.47 |
| Rate for Payer: AlohaCare Medicaid |
$425.50
|
| Rate for Payer: AlohaCare Medicare |
$425.50
|
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Devoted Health Medicare |
$468.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.21
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$258.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$425.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$808.45
|
| Rate for Payer: Health Management Network Commercial |
$723.35
|
| Rate for Payer: Humana Medicare |
$425.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$765.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$425.50
|
| Rate for Payer: MDX Hawaii PPO |
$825.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$425.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$425.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$425.50
|
| Rate for Payer: University Health Alliance Commercial |
$476.56
|
|
|
Fetal Non-Stress Test
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
8074275
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$723.35 |
| Max. Negotiated Rate |
$825.47 |
| Rate for Payer: Cash Price |
$553.15
|
| Rate for Payer: Health Management Network Commercial |
$723.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$765.90
|
| Rate for Payer: MDX Hawaii PPO |
$825.47
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$22,564.30
|
|
|
Service Code
|
MSDRG 864
|
| Min. Negotiated Rate |
$22,564.30 |
| Max. Negotiated Rate |
$22,564.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22,564.30
|
|
|
FFP 1 Unit FSI
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11641971
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: AlohaCare Medicaid |
$169.50
|
| Rate for Payer: AlohaCare Medicare |
$169.50
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Devoted Health Medicare |
$186.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.06
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Humana Medicare |
$169.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.50
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.50
|
| Rate for Payer: University Health Alliance Commercial |
$189.84
|
|
|
FFP 1 Unit FSI
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11641971
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$288.15 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
|
|
FFP 2 Units FSI
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11640498
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: AlohaCare Medicaid |
$169.50
|
| Rate for Payer: AlohaCare Medicare |
$169.50
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Devoted Health Medicare |
$186.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.06
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Humana Medicare |
$169.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.50
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.50
|
| Rate for Payer: University Health Alliance Commercial |
$189.84
|
|
|
FFP 2 Units FSI
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11640498
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$288.15 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
|
|
FFP 3 Units FSI
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11641972
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$288.15 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
|
|
FFP 3 Units FSI
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 86927
|
| Hospital Charge Code |
11641972
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: AlohaCare Medicaid |
$169.50
|
| Rate for Payer: AlohaCare Medicare |
$169.50
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Devoted Health Medicare |
$186.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.06
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Humana Medicare |
$169.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.50
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.50
|
| Rate for Payer: University Health Alliance Commercial |
$189.84
|
|
