|
MICRO OCD UNIVERSAL DRILL
|
Facility
|
IP
|
$1,526.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,297.10 |
| Max. Negotiated Rate |
$1,480.22 |
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Health Management Network Commercial |
$1,297.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,480.22
|
|
|
MICRO OCD UNIVERSAL DRILL
|
Facility
|
OP
|
$1,526.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$778.26 |
| Max. Negotiated Rate |
$1,480.22 |
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,449.70
|
| Rate for Payer: Health Management Network Commercial |
$1,297.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$961.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$778.26
|
| Rate for Payer: MDX Hawaii PPO |
$1,480.22
|
| Rate for Payer: University Health Alliance Commercial |
$1,112.30
|
|
|
MICROWAVE ABILATION APP 14CM
|
Facility
|
IP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,950.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
|
|
MICROWAVE ABILATION APP 14CM
|
Facility
|
OP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,570.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,650.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,410.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,570.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,102.30
|
|
|
MICROWAVE ABILATION APP 19CM
|
Facility
|
OP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,570.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,650.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,410.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,570.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,102.30
|
|
|
MICROWAVE ABILATION APP 19CM
|
Facility
|
IP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,950.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$376.00
|
|
|
Service Code
|
NDC 00054356699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.76 |
| Max. Negotiated Rate |
$364.72 |
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$357.20
|
| Rate for Payer: Health Management Network Commercial |
$319.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$236.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$191.76
|
| Rate for Payer: MDX Hawaii PPO |
$364.72
|
| Rate for Payer: University Health Alliance Commercial |
$274.07
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68094076262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$376.00
|
|
|
Service Code
|
NDC 00054356699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$319.60 |
| Max. Negotiated Rate |
$364.72 |
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Health Management Network Commercial |
$319.60
|
| Rate for Payer: MDX Hawaii PPO |
$364.72
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68094076262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68094076259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68094076259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J2251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
|
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J2251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.40
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [168902]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [168902]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
MIDDLE EAR EXPLORATION THROUGH POSTAURICULAR OR EAR CANAL INCISION
|
Facility
|
OP
|
$6,743.44
|
|
|
Service Code
|
CPT 69440
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,743.44 |
| Rate for Payer: AlohaCare Medicaid |
$3,916.70
|
| Rate for Payer: AlohaCare Medicare |
$3,916.70
|
| Rate for Payer: Devoted Health Medicare |
$4,308.37
|
| 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 |
$3,916.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$3,916.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,916.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,308.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,916.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,916.70
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
MIDODRINE 10 MG TABLET [33083]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687040925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
MIDODRINE 10 MG TABLET [33083]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687040925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
