|
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 56405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$66.23 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$359.99
|
| Rate for Payer: AlohaCare Medicare |
$359.99
|
| Rate for Payer: Devoted Health Medicare |
$395.99
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$449.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$359.99
|
| Rate for Payer: Humana Medicare |
$359.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$359.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$395.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$359.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$359.99
|
|
|
INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 46050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,098.60
|
| Rate for Payer: AlohaCare Medicare |
$1,098.60
|
| Rate for Payer: Devoted Health Medicare |
$1,208.46
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,373.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.60
|
| Rate for Payer: Humana Medicare |
$1,098.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,208.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.60
|
|
|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED
|
Facility
|
OP
|
$5,160.40
|
|
|
Service Code
|
CPT 10121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,951.11
|
| Rate for Payer: AlohaCare Medicare |
$1,951.11
|
| Rate for Payer: Devoted Health Medicare |
$2,146.22
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,438.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,951.11
|
| Rate for Payer: Humana Medicare |
$1,951.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,951.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,146.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,951.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,951.11
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$6,743.44
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,743.44 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| 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 |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
INCISION OF LINGUAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 41010
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,832.96
|
| Rate for Payer: AlohaCare Medicare |
$1,832.96
|
| Rate for Payer: Devoted Health Medicare |
$2,016.26
|
| 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 |
$1,832.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$1,832.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,832.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,016.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,832.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,832.96
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [10265]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
NDC 00517037505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Management Network Commercial |
$816.00
|
| Rate for Payer: MDX Hawaii PPO |
$931.20
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [187932]
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C9300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.20 |
| Max. Negotiated Rate |
$698.40 |
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$684.00
|
| Rate for Payer: Health Management Network Commercial |
$612.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$453.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$367.20
|
| Rate for Payer: MDX Hawaii PPO |
$698.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$432.00
|
| Rate for Payer: University Health Alliance Commercial |
$524.81
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [187932]
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C9300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$612.00 |
| Max. Negotiated Rate |
$698.40 |
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Health Management Network Commercial |
$612.00
|
| Rate for Payer: MDX Hawaii PPO |
$698.40
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
NDC 70100042401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
NDC 70100042402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$229.80
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
NDC 70100082502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$455.60 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 50268043011
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 68462040601
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 50268043015
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 68462040601
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 50268043015
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 50268043011
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
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
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$652.00
|
|
|
Service Code
|
NDC 69344010233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$554.20 |
| Max. Negotiated Rate |
$632.44 |
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Health Management Network Commercial |
$554.20
|
| Rate for Payer: MDX Hawaii PPO |
$632.44
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$619.00
|
|
|
Service Code
|
NDC 70710185206
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.69 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$588.05
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$389.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.69
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
| Rate for Payer: University Health Alliance Commercial |
$451.19
|
|
