|
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC
|
Facility
|
IP
|
$15,235.00
|
|
|
Service Code
|
MSDRG 798
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$15,235.00 |
| Rate for Payer: AlohaCare Medicare |
$10,886.30
|
| Rate for Payer: Devoted Health Medicare |
$11,974.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,044.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,886.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: Humana Medicare |
$10,886.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$15,235.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,886.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,886.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,886.30
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C
|
Facility
|
IP
|
$11,188.77
|
|
|
Service Code
|
APR-DRG 5424
|
| Min. Negotiated Rate |
$11,188.77 |
| Max. Negotiated Rate |
$11,188.77 |
| Rate for Payer: AlohaCare Medicaid |
$11,188.77
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11,188.77
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11,188.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11,188.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,188.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11,188.77
|
|
|
VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C
|
Facility
|
IP
|
$3,004.97
|
|
|
Service Code
|
APR-DRG 5421
|
| Min. Negotiated Rate |
$3,004.97 |
| Max. Negotiated Rate |
$3,004.97 |
| Rate for Payer: AlohaCare Medicaid |
$3,004.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,004.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,004.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,004.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,004.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,004.97
|
|
|
VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C
|
Facility
|
IP
|
$3,524.06
|
|
|
Service Code
|
APR-DRG 5422
|
| Min. Negotiated Rate |
$3,524.06 |
| Max. Negotiated Rate |
$3,524.06 |
| Rate for Payer: AlohaCare Medicaid |
$3,524.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,524.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,524.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,524.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,524.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,524.06
|
|
|
VAGINAL DELIVERY W O.R. PROCEDURE EXCEPT STERILIZATION &/OR D&C
|
Facility
|
IP
|
$4,799.26
|
|
|
Service Code
|
APR-DRG 5423
|
| Min. Negotiated Rate |
$4,799.26 |
| Max. Negotiated Rate |
$4,799.26 |
| Rate for Payer: AlohaCare Medicaid |
$4,799.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,799.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,799.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,799.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,799.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,799.26
|
|
|
VAGINAL DELIVERY W STERILIZATION &/OR D&C
|
Facility
|
IP
|
$4,177.41
|
|
|
Service Code
|
APR-DRG 5411
|
| Min. Negotiated Rate |
$4,177.41 |
| Max. Negotiated Rate |
$4,177.41 |
| Rate for Payer: AlohaCare Medicaid |
$4,177.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,177.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,177.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,177.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,177.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,177.41
|
|
|
VAGINAL DELIVERY W STERILIZATION &/OR D&C
|
Facility
|
IP
|
$4,263.67
|
|
|
Service Code
|
APR-DRG 5412
|
| Min. Negotiated Rate |
$4,263.67 |
| Max. Negotiated Rate |
$4,263.67 |
| Rate for Payer: AlohaCare Medicaid |
$4,263.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,263.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,263.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,263.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,263.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,263.67
|
|
|
VAGINAL DELIVERY W STERILIZATION &/OR D&C
|
Facility
|
IP
|
$5,214.07
|
|
|
Service Code
|
APR-DRG 5413
|
| Min. Negotiated Rate |
$5,214.07 |
| Max. Negotiated Rate |
$5,214.07 |
| Rate for Payer: AlohaCare Medicaid |
$5,214.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5,214.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5,214.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,214.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,214.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,214.07
|
|
|
VAGINAL DELIVERY W STERILIZATION &/OR D&C
|
Facility
|
IP
|
$9,050.93
|
|
|
Service Code
|
APR-DRG 5414
|
| Min. Negotiated Rate |
$9,050.93 |
| Max. Negotiated Rate |
$9,050.93 |
| Rate for Payer: AlohaCare Medicaid |
$9,050.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9,050.93
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9,050.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,050.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,050.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,050.93
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
|
Facility
|
OP
|
$24,500.00
|
|
|
Service Code
|
CPT 58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$24,500.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,909.62
|
| Rate for Payer: AlohaCare Medicare |
$5,909.62
|
| Rate for Payer: Devoted Health Medicare |
$6,500.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,900.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,395.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,909.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,695.11
|
| Rate for Payer: Humana Medicare |
$5,909.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,909.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,500.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,909.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,909.62
|
| Rate for Payer: University Health Alliance Commercial |
$24,500.00
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)
|
Facility
|
OP
|
$24,500.00
|
|
|
Service Code
|
CPT 58262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$24,500.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,909.62
|
| Rate for Payer: AlohaCare Medicare |
$5,909.62
|
| Rate for Payer: Devoted Health Medicare |
$6,500.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,900.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,395.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,909.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,695.11
|
| Rate for Payer: Humana Medicare |
$5,909.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,909.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,500.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,909.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,909.62
|
| Rate for Payer: University Health Alliance Commercial |
$24,500.00
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
|
Facility
|
OP
|
$14,395.00
|
|
|
Service Code
|
CPT 58290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$14,395.00 |
| Rate for Payer: AlohaCare Medicaid |
$8,760.19
|
| Rate for Payer: AlohaCare Medicare |
$8,760.19
|
| Rate for Payer: Devoted Health Medicare |
$9,636.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,900.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,395.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,760.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,695.11
|
| Rate for Payer: Humana Medicare |
$8,760.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,760.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,636.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,760.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,760.19
|
| Rate for Payer: University Health Alliance Commercial |
$13,923.44
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
|
Facility
|
OP
|
$24,500.00
|
|
|
Service Code
|
CPT 58291
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$24,500.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,909.62
|
| Rate for Payer: AlohaCare Medicare |
$5,909.62
|
| Rate for Payer: Devoted Health Medicare |
$6,500.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,102.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,192.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,909.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,561.00
|
| Rate for Payer: Humana Medicare |
$5,909.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,909.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,500.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,909.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,909.62
|
| Rate for Payer: University Health Alliance Commercial |
$24,500.00
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 50268078915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084030911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084030911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084030921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 50268078915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084030921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 68084021511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 68084021521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 68084021501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68084021501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68084021511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 68084021521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
