|
RXSIGHT LIGHT ADJUSTABLE LENS PLUS (RXLAL)
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
13046233
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,000.00
|
| Rate for Payer: AlohaCare Medicare |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Devoted Health Medicare |
$1,100.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,000.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Humana Medicare |
$1,000.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,000.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,000.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,000.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,000.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
RXSIGHT LIGHT ADJUSTABLE LENS PLUS (RXLAL)
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
13046233
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
RXSIGHT LIGHT ADJUSTABLE LENS (RXLAL)
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
13032584
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,000.00
|
| Rate for Payer: AlohaCare Medicare |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Devoted Health Medicare |
$1,100.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,000.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Humana Medicare |
$1,000.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,000.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,000.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,000.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,000.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
RXSIGHT LIGHT ADJUSTABLE LENS (RXLAL)
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
13032584
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
S0119 Ondansetron, oral, 4 mg
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS S0119
|
| Hospital Charge Code |
8122167
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.59 |
| Max. Negotiated Rate |
$73.95 |
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Cash Price |
$56.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.59
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
|
|
S0285 Consult Before Screen Colonosc
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS S0285
|
| Hospital Charge Code |
9379162
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| 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 |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente 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 |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| 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 |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
S9088 Services provided in an urgent care center
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS S9088
|
| Hospital Charge Code |
8467254
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$39.33 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| 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 |
$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 |
$39.33
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| 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 |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| 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 |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
S9480 Intensive Outpatient Psychiatric Services
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS S9480
|
| Hospital Charge Code |
11415547
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$195.50 |
| Max. Negotiated Rate |
$195.50 |
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Health Management Network Commercial |
$195.50
|
|
|
Salicylate FSI
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8118042
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$168.30 |
| Max. Negotiated Rate |
$192.06 |
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Health Management Network Commercial |
$168.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.20
|
| Rate for Payer: MDX Hawaii PPO |
$192.06
|
|
|
Salicylate FSI
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8118042
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$192.06 |
| Rate for Payer: AlohaCare Medicaid |
$99.00
|
| Rate for Payer: AlohaCare Medicare |
$99.00
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Cash Price |
$128.70
|
| Rate for Payer: Devoted Health Medicare |
$108.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$143.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$188.10
|
| Rate for Payer: Health Management Network Commercial |
$168.30
|
| Rate for Payer: Humana Medicare |
$99.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.00
|
| Rate for Payer: MDX Hawaii PPO |
$192.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.00
|
| Rate for Payer: University Health Alliance Commercial |
$110.88
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$21,758.44
|
|
|
Service Code
|
MSDRG 139
|
| Min. Negotiated Rate |
$21,758.44 |
| Max. Negotiated Rate |
$21,758.44 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,758.44
|
|
|
SARS CoV-2 and Influenza PCR FSI
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS 87636 QW
|
| Hospital Charge Code |
9343541
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$476.85 |
| Max. Negotiated Rate |
$544.17 |
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Health Management Network Commercial |
$476.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.90
|
| Rate for Payer: MDX Hawaii PPO |
$544.17
|
|
|
SARS CoV-2 and Influenza PCR FSI
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS 87636 QW
|
| Hospital Charge Code |
9343541
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$142.63 |
| Max. Negotiated Rate |
$544.17 |
| Rate for Payer: AlohaCare Medicaid |
$280.50
|
| Rate for Payer: AlohaCare Medicare |
$280.50
|
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Cash Price |
$364.65
|
| Rate for Payer: Devoted Health Medicare |
$308.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$142.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$178.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$280.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$142.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.63
|
| Rate for Payer: Health Management Network Commercial |
$476.85
|
| Rate for Payer: Humana Medicare |
$280.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$286.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$280.50
|
| Rate for Payer: MDX Hawaii PPO |
$544.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$280.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$280.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$280.50
|
| Rate for Payer: University Health Alliance Commercial |
$314.16
|
|
|
SARS-CoV-2 (COVID-19) AG (Sofia) POC (RE)
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
HCPCS 87428 QW
|
| Hospital Charge Code |
9578803
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: AlohaCare Medicaid |
$294.50
|
| Rate for Payer: AlohaCare Medicare |
$294.50
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Devoted Health Medicare |
$323.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$73.49
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$294.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$73.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.29
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Humana Medicare |
$294.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$530.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$300.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$294.50
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$294.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$294.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$294.50
|
| Rate for Payer: University Health Alliance Commercial |
$329.84
|
|
|
SARS-CoV-2 (COVID-19) AG (Sofia) POC (RE)
|
Professional
|
Both
|
$589.00
|
|
|
Service Code
|
HCPCS 87428 QW
|
| Hospital Charge Code |
9578803
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$500.65 |
| Rate for Payer: AlohaCare Medicaid |
$63.59
|
| Rate for Payer: AlohaCare Medicare |
$70.29
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Devoted Health Medicare |
$77.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.50
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.29
|
|
|
SARS-CoV-2 (COVID-19) AG (Sofia) POC (RE)
|
Facility
|
IP
|
$589.00
|
|
|
Service Code
|
HCPCS 87428 QW
|
| Hospital Charge Code |
9578803
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$500.65 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$530.10
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
|
|
SARS-CoV-2 (Covid-19) AG (Sofia) POCT
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
HCPCS 87426 QW
|
| Hospital Charge Code |
9578812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.33 |
| Max. Negotiated Rate |
$236.68 |
| Rate for Payer: AlohaCare Medicaid |
$122.00
|
| Rate for Payer: AlohaCare Medicare |
$122.00
|
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Devoted Health Medicare |
$134.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$45.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$44.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$122.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$45.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.33
|
| Rate for Payer: Health Management Network Commercial |
$207.40
|
| Rate for Payer: Humana Medicare |
$122.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$122.00
|
| Rate for Payer: MDX Hawaii PPO |
$236.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$122.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$122.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$122.00
|
| Rate for Payer: University Health Alliance Commercial |
$136.64
|
|
|
SARS-CoV-2 (Covid-19) AG (Sofia) POCT
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS 87426 QW
|
| Hospital Charge Code |
9578812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$207.40 |
| Max. Negotiated Rate |
$236.68 |
| Rate for Payer: Cash Price |
$158.60
|
| Rate for Payer: Health Management Network Commercial |
$207.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.60
|
| Rate for Payer: MDX Hawaii PPO |
$236.68
|
|
|
SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS U0001
|
| Hospital Charge Code |
8855655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.91 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: AlohaCare Medicaid |
$122.50
|
| Rate for Payer: AlohaCare Medicare |
$122.50
|
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Devoted Health Medicare |
$134.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$44.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$122.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$232.75
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Humana Medicare |
$122.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$122.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$122.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$122.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$122.50
|
| Rate for Payer: University Health Alliance Commercial |
$137.20
|
|
|
SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS U0001
|
| Hospital Charge Code |
8855655
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
|
|
SARS-CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8867164
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
SARS-CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8867164
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
SARS-CoV-2 (COVID-19)/FLU AB (Sofia) POC (RE)
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
HCPCS 87428 QW
|
| Hospital Charge Code |
9578804
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$63.59 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: AlohaCare Medicaid |
$294.50
|
| Rate for Payer: AlohaCare Medicare |
$294.50
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Devoted Health Medicare |
$323.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$73.49
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$294.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$73.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.29
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Humana Medicare |
$294.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$530.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$300.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$294.50
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$294.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$294.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$294.50
|
| Rate for Payer: University Health Alliance Commercial |
$329.84
|
|
|
SARS-CoV-2 (COVID-19)/FLU AB (Sofia) POC (RE)
|
Facility
|
IP
|
$589.00
|
|
|
Service Code
|
HCPCS 87428 QW
|
| Hospital Charge Code |
9578804
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$500.65 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: Cash Price |
$382.85
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$530.10
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
|
|
SARS-CoV-2 (COVID-19) IgG Antibody, Qual FSI
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS 86769
|
| Hospital Charge Code |
8879007
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.13 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicare |
$54.50
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Devoted Health Medicare |
$59.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$42.13
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$52.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.13
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Humana Medicare |
$54.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.50
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.50
|
| Rate for Payer: University Health Alliance Commercial |
$61.04
|
|
