|
VITAL CAPACITY TEST CHARGE
|
Facility
|
IP
|
$426.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
8243399
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$362.10 |
| Max. Negotiated Rate |
$413.22 |
| Rate for Payer: Cash Price |
$276.90
|
| Rate for Payer: Health Management Network Commercial |
$362.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$383.40
|
| Rate for Payer: MDX Hawaii PPO |
$413.22
|
|
|
VITAL CAPACITY TEST CHARGE
|
Facility
|
OP
|
$426.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
8243399
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$413.22 |
| Rate for Payer: AlohaCare Medicaid |
$213.00
|
| Rate for Payer: AlohaCare Medicare |
$213.00
|
| Rate for Payer: Cash Price |
$276.90
|
| Rate for Payer: Cash Price |
$276.90
|
| Rate for Payer: Devoted Health Medicare |
$234.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.54
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$164.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$213.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$404.70
|
| Rate for Payer: Health Management Network Commercial |
$362.10
|
| Rate for Payer: Humana Medicare |
$213.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$383.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$217.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$213.00
|
| Rate for Payer: MDX Hawaii PPO |
$413.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$213.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$213.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$213.00
|
| Rate for Payer: University Health Alliance Commercial |
$238.56
|
|
|
vitamin A and D oint 113 gm [HHSC]
|
Facility
|
IP
|
$26.69
|
|
|
Service Code
|
NDC 71399012204
|
| Hospital Charge Code |
2501127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.69 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
|
|
vitamin A and D oint 113 gm [HHSC]
|
Facility
|
OP
|
$26.69
|
|
|
Service Code
|
NDC 71399012204
|
| Hospital Charge Code |
2501127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.35
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: University Health Alliance Commercial |
$19.45
|
|
|
Vitamin A (Retinol) FSI
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 84590
|
| Hospital Charge Code |
8118082
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$114.75 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
|
|
Vitamin A (Retinol) FSI
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 84590
|
| Hospital Charge Code |
8118082
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: AlohaCare Medicaid |
$67.50
|
| Rate for Payer: AlohaCare Medicare |
$67.50
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Cash Price |
$87.75
|
| Rate for Payer: Devoted Health Medicare |
$74.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$67.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.61
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Humana Medicare |
$67.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.50
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$67.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$67.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$67.50
|
| Rate for Payer: University Health Alliance Commercial |
$29.97
|
|
|
Vitamin B12 Binding Capacity FSI
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
HCPCS 82608
|
| Hospital Charge Code |
8228942
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: AlohaCare Medicaid |
$82.00
|
| Rate for Payer: AlohaCare Medicare |
$82.00
|
| Rate for Payer: Cash Price |
$106.60
|
| Rate for Payer: Cash Price |
$106.60
|
| Rate for Payer: Devoted Health Medicare |
$90.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$19.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.32
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Humana Medicare |
$82.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.00
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.00
|
| Rate for Payer: University Health Alliance Commercial |
$37.02
|
|
|
Vitamin B12 Binding Capacity FSI
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS 82608
|
| Hospital Charge Code |
8228942
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$139.40 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: Cash Price |
$106.60
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
|
|
Vitamin B12 FSI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 82607
|
| Hospital Charge Code |
8118083
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$86.50
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Devoted Health Medicare |
$95.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.08
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$86.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.50
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.50
|
| Rate for Payer: University Health Alliance Commercial |
$38.96
|
|
|
Vitamin B12 FSI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 82607
|
| Hospital Charge Code |
8118083
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
Vitamin B1 Whole Blood FSI
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
8228941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.23 |
| 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 |
$26.36
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.23
|
| 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 |
$26.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.50
|
| Rate for Payer: University Health Alliance Commercial |
$49.30
|
|
|
Vitamin B1 Whole Blood FSI
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
8228941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
Vitamin D, 1,25 Dihydroxy REF
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
HCPCS 82652
|
| Hospital Charge Code |
8160100
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$184.45 |
| Max. Negotiated Rate |
$210.49 |
| Rate for Payer: Cash Price |
$141.05
|
| Rate for Payer: Health Management Network Commercial |
$184.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$195.30
|
| Rate for Payer: MDX Hawaii PPO |
$210.49
|
|
|
Vitamin D, 1,25 Dihydroxy REF
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
HCPCS 82652
|
| Hospital Charge Code |
8160100
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$210.49 |
| Rate for Payer: AlohaCare Medicaid |
$108.50
|
| Rate for Payer: AlohaCare Medicare |
$108.50
|
| Rate for Payer: Cash Price |
$141.05
|
| Rate for Payer: Cash Price |
$141.05
|
| Rate for Payer: Devoted Health Medicare |
$119.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$53.19
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$48.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$55.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.50
|
| Rate for Payer: Health Management Network Commercial |
$184.45
|
| Rate for Payer: Humana Medicare |
$108.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$195.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$110.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.50
|
| Rate for Payer: MDX Hawaii PPO |
$210.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.50
|
| Rate for Payer: University Health Alliance Commercial |
$99.49
|
|
|
Vitamin D (25-OH), Total FSI
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
8118084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$269.45 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
|
|
Vitamin D (25-OH), Total FSI
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
8118084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: AlohaCare Medicaid |
$158.50
|
| Rate for Payer: AlohaCare Medicare |
$158.50
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Devoted Health Medicare |
$174.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.60
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Humana Medicare |
$158.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.50
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.52
|
|
|
Vitamin D2, D3, and Total 25-OH FSI
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
8118085
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$269.45 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
|
|
Vitamin D2, D3, and Total 25-OH FSI
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
8118085
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: AlohaCare Medicaid |
$158.50
|
| Rate for Payer: AlohaCare Medicare |
$158.50
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Devoted Health Medicare |
$174.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.60
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Humana Medicare |
$158.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.50
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.52
|
|
|
Vitamin D (Total)
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
10408974
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$269.45 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
|
|
Vitamin D (Total)
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
10408974
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: AlohaCare Medicaid |
$158.50
|
| Rate for Payer: AlohaCare Medicare |
$158.50
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Devoted Health Medicare |
$174.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.60
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Humana Medicare |
$158.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.50
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.52
|
|
|
Vitamin D (Total) FSI
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
10408969
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$269.45 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
|
|
Vitamin D (Total) FSI
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS 82306
|
| Hospital Charge Code |
10408969
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: AlohaCare Medicaid |
$158.50
|
| Rate for Payer: AlohaCare Medicare |
$158.50
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Cash Price |
$206.05
|
| Rate for Payer: Devoted Health Medicare |
$174.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.60
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Humana Medicare |
$158.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.50
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.52
|
|
|
Vitamin E, Tocopherol FSI
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
HCPCS 84446
|
| Hospital Charge Code |
8118086
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$136.85 |
| Max. Negotiated Rate |
$156.17 |
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Health Management Network Commercial |
$136.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.90
|
| Rate for Payer: MDX Hawaii PPO |
$156.17
|
|
|
Vitamin E, Tocopherol FSI
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
HCPCS 84446
|
| Hospital Charge Code |
8118086
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$156.17 |
| Rate for Payer: AlohaCare Medicaid |
$80.50
|
| Rate for Payer: AlohaCare Medicare |
$80.50
|
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Cash Price |
$104.65
|
| Rate for Payer: Devoted Health Medicare |
$88.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$19.60
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.18
|
| Rate for Payer: Health Management Network Commercial |
$136.85
|
| Rate for Payer: Humana Medicare |
$80.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$82.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.50
|
| Rate for Payer: MDX Hawaii PPO |
$156.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.50
|
| Rate for Payer: University Health Alliance Commercial |
$36.65
|
|
|
Vitamin K Level FSI
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
HCPCS 84597
|
| Hospital Charge Code |
10046564
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$78.50
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Devoted Health Medicare |
$86.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.72
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$78.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.50
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.43
|
|
