|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [134080]
|
Facility
|
IP
|
$6,875.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,843.75 |
| Max. Negotiated Rate |
$6,668.75 |
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Health Management Network Commercial |
$5,843.75
|
| Rate for Payer: MDX Hawaii PPO |
$6,668.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [134080]
|
Facility
|
OP
|
$6,875.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$6,668.75 |
| Rate for Payer: AlohaCare Medicaid |
$1.84
|
| Rate for Payer: AlohaCare Medicare |
$1.84
|
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Devoted Health Medicare |
$2.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,531.25
|
| Rate for Payer: Health Management Network Commercial |
$5,843.75
|
| Rate for Payer: Humana Medicare |
$1.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,331.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,506.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.84
|
| Rate for Payer: MDX Hawaii PPO |
$6,668.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,125.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.84
|
| Rate for Payer: University Health Alliance Commercial |
$5,011.19
|
|
|
COAGULATION & PLATELET DISORDERS
|
Facility
|
IP
|
$3,490.99
|
|
|
Service Code
|
APR-DRG 6611
|
| Min. Negotiated Rate |
$3,490.99 |
| Max. Negotiated Rate |
$3,490.99 |
| Rate for Payer: AlohaCare Medicaid |
$3,490.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,490.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,490.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,490.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,490.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,490.99
|
|
|
COAGULATION & PLATELET DISORDERS
|
Facility
|
IP
|
$13,149.25
|
|
|
Service Code
|
APR-DRG 6614
|
| Min. Negotiated Rate |
$13,149.25 |
| Max. Negotiated Rate |
$13,149.25 |
| Rate for Payer: AlohaCare Medicaid |
$13,149.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13,149.25
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13,149.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13,149.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13,149.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13,149.25
|
|
|
COAGULATION & PLATELET DISORDERS
|
Facility
|
IP
|
$4,816.41
|
|
|
Service Code
|
APR-DRG 6612
|
| Min. Negotiated Rate |
$4,816.41 |
| Max. Negotiated Rate |
$4,816.41 |
| Rate for Payer: AlohaCare Medicaid |
$4,816.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,816.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,816.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,816.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,816.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,816.41
|
|
|
COAGULATION & PLATELET DISORDERS
|
Facility
|
IP
|
$7,356.38
|
|
|
Service Code
|
APR-DRG 6613
|
| Min. Negotiated Rate |
$7,356.38 |
| Max. Negotiated Rate |
$7,356.38 |
| Rate for Payer: AlohaCare Medicaid |
$7,356.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7,356.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7,356.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,356.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,356.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,356.38
|
|
|
COAL TAR 0.5 % SHAMPOO [27670]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 00904525944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
COAL TAR 0.5 % SHAMPOO [27670]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 00904525944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
COCAINE ABUSE & DEPENDENCE
|
Facility
|
IP
|
$2,492.64
|
|
|
Service Code
|
APR-DRG 7742
|
| Min. Negotiated Rate |
$2,492.64 |
| Max. Negotiated Rate |
$2,492.64 |
| Rate for Payer: AlohaCare Medicaid |
$2,492.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,492.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,492.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,492.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,492.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,492.64
|
|
|
COCAINE ABUSE & DEPENDENCE
|
Facility
|
IP
|
$2,360.62
|
|
|
Service Code
|
APR-DRG 7741
|
| Min. Negotiated Rate |
$2,360.62 |
| Max. Negotiated Rate |
$2,360.62 |
| Rate for Payer: AlohaCare Medicaid |
$2,360.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,360.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,360.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,360.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,360.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,360.62
|
|
|
COCAINE ABUSE & DEPENDENCE
|
Facility
|
IP
|
$12,671.75
|
|
|
Service Code
|
APR-DRG 7744
|
| Min. Negotiated Rate |
$12,671.75 |
| Max. Negotiated Rate |
$12,671.75 |
| Rate for Payer: AlohaCare Medicaid |
$12,671.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12,671.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12,671.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12,671.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,671.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12,671.75
|
|
|
COCAINE ABUSE & DEPENDENCE
|
Facility
|
IP
|
$4,425.70
|
|
|
Service Code
|
APR-DRG 7743
|
| Min. Negotiated Rate |
$4,425.70 |
| Max. Negotiated Rate |
$4,425.70 |
| Rate for Payer: AlohaCare Medicaid |
$4,425.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,425.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,425.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,425.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,425.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,425.70
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00121177540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00121177500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00121177505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00121177500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00121177505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00121177540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00527169801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00527169801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 50268018715
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 60687072711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 50268018711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 50268018715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 60687072711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
