|
DRSG WOUND VAC MED
|
Facility
|
OP
|
$211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.61 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$200.45
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.61
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
| Rate for Payer: University Health Alliance Commercial |
$153.80
|
|
|
DRSG WOUND VAC MED
|
Facility
|
IP
|
$211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.35 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
|
|
DRSG WOUND VAC SM
|
Facility
|
IP
|
$171.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.35 |
| Max. Negotiated Rate |
$165.87 |
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Health Management Network Commercial |
$145.35
|
| Rate for Payer: MDX Hawaii PPO |
$165.87
|
|
|
DRSG WOUND VAC SM
|
Facility
|
OP
|
$171.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.21 |
| Max. Negotiated Rate |
$165.87 |
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$162.45
|
| Rate for Payer: Health Management Network Commercial |
$145.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.21
|
| Rate for Payer: MDX Hawaii PPO |
$165.87
|
| Rate for Payer: University Health Alliance Commercial |
$124.64
|
|
|
DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$1,363.72
|
|
|
Service Code
|
APR-DRG 7701
|
| Min. Negotiated Rate |
$1,363.72 |
| Max. Negotiated Rate |
$1,363.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,363.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,363.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,363.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,363.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,363.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,363.72
|
|
|
DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$2,142.34
|
|
|
Service Code
|
APR-DRG 7702
|
| Min. Negotiated Rate |
$2,142.34 |
| Max. Negotiated Rate |
$2,142.34 |
| Rate for Payer: AlohaCare Medicaid |
$2,142.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,142.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,142.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,142.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,142.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,142.34
|
|
|
DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$3,610.32
|
|
|
Service Code
|
APR-DRG 7703
|
| Min. Negotiated Rate |
$3,610.32 |
| Max. Negotiated Rate |
$3,610.32 |
| Rate for Payer: AlohaCare Medicaid |
$3,610.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,610.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,610.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,610.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,610.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,610.32
|
|
|
DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE
|
Facility
|
IP
|
$8,062.27
|
|
|
Service Code
|
APR-DRG 7704
|
| Min. Negotiated Rate |
$8,062.27 |
| Max. Negotiated Rate |
$8,062.27 |
| Rate for Payer: AlohaCare Medicaid |
$8,062.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8,062.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8,062.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,062.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,062.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,062.27
|
|
|
DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 42975
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$98.96 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,102.67
|
| Rate for Payer: AlohaCare Medicare |
$2,102.67
|
| Rate for Payer: Devoted Health Medicare |
$2,312.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,102.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$2,102.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,102.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,312.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,102.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,102.67
|
|
|
DUALKNIFE J UPPER LGTH KD-655L
|
Facility
|
IP
|
$2,909.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,472.65 |
| Max. Negotiated Rate |
$2,821.73 |
| Rate for Payer: Cash Price |
$1,745.40
|
| Rate for Payer: Health Management Network Commercial |
$2,472.65
|
| Rate for Payer: MDX Hawaii PPO |
$2,821.73
|
|
|
DUALKNIFE J UPPER LGTH KD-655L
|
Facility
|
OP
|
$2,909.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,483.59 |
| Max. Negotiated Rate |
$2,821.73 |
| Rate for Payer: Cash Price |
$1,745.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,763.55
|
| Rate for Payer: Health Management Network Commercial |
$2,472.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,832.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,483.59
|
| Rate for Payer: MDX Hawaii PPO |
$2,821.73
|
| Rate for Payer: University Health Alliance Commercial |
$2,120.37
|
|
|
DUAL PORT COAXIAL INTRO KIT
|
Facility
|
OP
|
$1,365.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$696.15 |
| Max. Negotiated Rate |
$1,324.05 |
| Rate for Payer: Cash Price |
$819.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,296.75
|
| Rate for Payer: Health Management Network Commercial |
$1,160.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$859.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$696.15
|
| Rate for Payer: MDX Hawaii PPO |
$1,324.05
|
| Rate for Payer: University Health Alliance Commercial |
$994.95
|
|
|
DUAL PORT COAXIAL INTRO KIT
|
Facility
|
IP
|
$1,365.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,160.25 |
| Max. Negotiated Rate |
$1,324.05 |
| Rate for Payer: Cash Price |
$819.00
|
| Rate for Payer: Health Management Network Commercial |
$1,160.25
|
| Rate for Payer: MDX Hawaii PPO |
$1,324.05
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 68084067521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 27241009706
|
|
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
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00904704304
|
|
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
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687072311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 27241009706
|
|
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
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00904704304
|
|
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
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687072311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 68084067521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 68180029506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 60687073401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 60687073411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 60687073411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
