|
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS
|
Facility
|
IP
|
$6,968.93
|
|
|
Service Code
|
APR-DRG 4224
|
| Min. Negotiated Rate |
$6,968.93 |
| Max. Negotiated Rate |
$6,968.93 |
| Rate for Payer: AlohaCare Medicaid |
$6,968.93
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6,968.93
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6,968.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,968.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,968.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,968.93
|
|
|
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS
|
Facility
|
IP
|
$3,885.61
|
|
|
Service Code
|
APR-DRG 4223
|
| Min. Negotiated Rate |
$3,885.61 |
| Max. Negotiated Rate |
$3,885.61 |
| Rate for Payer: AlohaCare Medicaid |
$3,885.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,885.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,885.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,885.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,885.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,885.61
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$5,509.00
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,509.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,824.16
|
| Rate for Payer: AlohaCare Medicare |
$3,824.16
|
| Rate for Payer: Devoted Health Medicare |
$4,206.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,824.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$3,824.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,824.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,206.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,824.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,824.16
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$24,500.00
|
|
|
Service Code
|
CPT 58563
|
|
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 |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,909.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| 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
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$6,743.44
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,743.44 |
| Rate for Payer: AlohaCare Medicaid |
$3,824.16
|
| Rate for Payer: AlohaCare Medicare |
$3,824.16
|
| Rate for Payer: Devoted Health Medicare |
$4,206.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,824.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$3,824.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,824.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,206.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,824.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,824.16
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$13,778.00 |
| 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 |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,909.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| 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 |
$6,743.44
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$8,270.00
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$8,270.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,824.16
|
| Rate for Payer: AlohaCare Medicare |
$3,824.16
|
| Rate for Payer: Devoted Health Medicare |
$4,206.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8,270.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,824.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,427.62
|
| Rate for Payer: Humana Medicare |
$3,824.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,824.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,206.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,824.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,824.16
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00121091405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 68001052192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00121091400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00121091405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68094049461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68094049461
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 68001052192
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00121091400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
IBUPROFEN 400 MG TABLET [3843]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904585361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
IBUPROFEN 400 MG TABLET [3843]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904585361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
IBUPROFEN 400 MG TABLET [3843]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687044601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
IBUPROFEN 400 MG TABLET [3843]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687044601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687045711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687045701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904585461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687045701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904585461
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
IBUPROFEN 600 MG TABLET [3844]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687045711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
