|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$10,406.43
|
|
|
Service Code
|
APR-DRG 2804
|
| Min. Negotiated Rate |
$10,406.43 |
| Max. Negotiated Rate |
$10,406.43 |
| Rate for Payer: AlohaCare Medicaid |
$10,406.43
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10,406.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10,406.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,406.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,406.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,406.43
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$5,123.64
|
|
|
Service Code
|
APR-DRG 2803
|
| Min. Negotiated Rate |
$5,123.64 |
| Max. Negotiated Rate |
$5,123.64 |
| Rate for Payer: AlohaCare Medicaid |
$5,123.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5,123.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5,123.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,123.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,123.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,123.64
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$3,472.07
|
|
|
Service Code
|
APR-DRG 2802
|
| Min. Negotiated Rate |
$3,472.07 |
| Max. Negotiated Rate |
$3,472.07 |
| Rate for Payer: AlohaCare Medicaid |
$3,472.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,472.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,472.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,472.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,472.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,472.07
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$2,792.40
|
|
|
Service Code
|
APR-DRG 2801
|
| Min. Negotiated Rate |
$2,792.40 |
| Max. Negotiated Rate |
$2,792.40 |
| Rate for Payer: AlohaCare Medicaid |
$2,792.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,792.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,792.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,792.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,792.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,792.40
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
NDC 65862032904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
NDC 64980034214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 64980034214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.52 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.40
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.52
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
| Rate for Payer: University Health Alliance Commercial |
$37.90
|
|
|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 65862032904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.52 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.40
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.52
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
| Rate for Payer: University Health Alliance Commercial |
$37.90
|
|
|
ALEXIS CONTAINED EXTRACT GTB17
|
Facility
|
OP
|
$1,278.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$651.78 |
| Max. Negotiated Rate |
$1,239.66 |
| Rate for Payer: Cash Price |
$766.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,214.10
|
| Rate for Payer: Health Management Network Commercial |
$1,086.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$805.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$651.78
|
| Rate for Payer: MDX Hawaii PPO |
$1,239.66
|
| Rate for Payer: University Health Alliance Commercial |
$931.53
|
|
|
ALEXIS CONTAINED EXTRACT GTB17
|
Facility
|
IP
|
$1,278.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,086.30 |
| Max. Negotiated Rate |
$1,239.66 |
| Rate for Payer: Cash Price |
$766.80
|
| Rate for Payer: Health Management Network Commercial |
$1,086.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,239.66
|
|
|
ALEXIS WOUND PROTECTOR C8322
|
Facility
|
IP
|
$248.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.80 |
| Max. Negotiated Rate |
$240.56 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
|
|
ALEXIS WOUND PROTECTOR C8322
|
Facility
|
OP
|
$248.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$126.48 |
| Max. Negotiated Rate |
$240.56 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$235.60
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$126.48
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
| Rate for Payer: University Health Alliance Commercial |
$180.77
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$2,516.48
|
|
|
Service Code
|
APR-DRG 8112
|
| Min. Negotiated Rate |
$2,516.48 |
| Max. Negotiated Rate |
$2,516.48 |
| Rate for Payer: AlohaCare Medicaid |
$2,516.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,516.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,516.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,516.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,516.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,516.48
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$9,548.68
|
|
|
Service Code
|
APR-DRG 8114
|
| Min. Negotiated Rate |
$9,548.68 |
| Max. Negotiated Rate |
$9,548.68 |
| Rate for Payer: AlohaCare Medicaid |
$9,548.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9,548.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9,548.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,548.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,548.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,548.68
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$4,763.58
|
|
|
Service Code
|
APR-DRG 8113
|
| Min. Negotiated Rate |
$4,763.58 |
| Max. Negotiated Rate |
$4,763.58 |
| Rate for Payer: AlohaCare Medicaid |
$4,763.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,763.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,763.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,763.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,763.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,763.58
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$1,720.05
|
|
|
Service Code
|
APR-DRG 8111
|
| Min. Negotiated Rate |
$1,720.05 |
| Max. Negotiated Rate |
$1,720.05 |
| Rate for Payer: AlohaCare Medicaid |
$1,720.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,720.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,720.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,720.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,720.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,720.05
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
|
IP
|
$29,007.60
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$13,443.36 |
| Max. Negotiated Rate |
$29,007.60 |
| Rate for Payer: AlohaCare Medicare |
$19,126.94
|
| Rate for Payer: Devoted Health Medicare |
$21,039.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,443.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19,126.94
|
| Rate for Payer: Humana Medicare |
$19,126.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$29,007.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$19,126.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$19,126.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$19,126.94
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
|
IP
|
$13,443.36
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$7,578.67 |
| Max. Negotiated Rate |
$13,443.36 |
| Rate for Payer: AlohaCare Medicare |
$7,578.67
|
| Rate for Payer: Devoted Health Medicare |
$8,336.54
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,443.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,578.67
|
| Rate for Payer: Humana Medicare |
$7,578.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,493.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,578.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,578.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,578.67
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$234,409.56
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$234,409.56 |
| Rate for Payer: AlohaCare Medicare |
$136,694.66
|
| Rate for Payer: Devoted Health Medicare |
$150,364.13
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$234,409.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$136,694.66
|
| Rate for Payer: Humana Medicare |
$136,694.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$207,308.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$136,694.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$136,694.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$136,694.66
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$104,253.43
|
|
|
Service Code
|
APR-DRG 0074
|
| Min. Negotiated Rate |
$104,253.43 |
| Max. Negotiated Rate |
$104,253.43 |
| Rate for Payer: AlohaCare Medicaid |
$104,253.43
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104,253.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104,253.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104,253.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104,253.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$104,253.43
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$42,270.81
|
|
|
Service Code
|
APR-DRG 0071
|
| Min. Negotiated Rate |
$42,270.81 |
| Max. Negotiated Rate |
$42,270.81 |
| Rate for Payer: AlohaCare Medicaid |
$42,270.81
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$42,270.81
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$42,270.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42,270.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42,270.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42,270.81
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$46,999.82
|
|
|
Service Code
|
APR-DRG 0072
|
| Min. Negotiated Rate |
$46,999.82 |
| Max. Negotiated Rate |
$46,999.82 |
| Rate for Payer: AlohaCare Medicaid |
$46,999.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$46,999.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$46,999.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46,999.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46,999.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46,999.82
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$68,078.15
|
|
|
Service Code
|
APR-DRG 0073
|
| Min. Negotiated Rate |
$68,078.15 |
| Max. Negotiated Rate |
$68,078.15 |
| Rate for Payer: AlohaCare Medicaid |
$68,078.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$68,078.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$68,078.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68,078.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68,078.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68,078.15
|
|
|
ALLOGRAFT 10.0X64 FGL10064
|
Facility
|
IP
|
$7,040.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,942.40 |
| Max. Negotiated Rate |
$6,828.80 |
| Rate for Payer: Cash Price |
$4,224.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,928.00
|
| Rate for Payer: Health Management Network Commercial |
$5,984.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,828.80
|
| Rate for Payer: University Health Alliance Commercial |
$3,942.40
|
|
|
ALLOGRAFT 10.0X64 FGL10064
|
Facility
|
OP
|
$7,040.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,590.40 |
| Max. Negotiated Rate |
$6,828.80 |
| Rate for Payer: Cash Price |
$4,224.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,928.00
|
| Rate for Payer: Health Management Network Commercial |
$5,984.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,435.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,590.40
|
| Rate for Payer: MDX Hawaii PPO |
$6,828.80
|
| Rate for Payer: University Health Alliance Commercial |
$3,942.40
|
|
