|
NURSE VISIT ONLY - FACILITY ONLY
|
Facility
|
OP
|
$513.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
761G046302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.65 |
| Max. Negotiated Rate |
$497.61 |
| Rate for Payer: AlohaCare Medicaid |
$157.28
|
| Rate for Payer: AlohaCare Medicare |
$157.28
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Devoted Health Medicare |
$173.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$196.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$157.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$487.35
|
| Rate for Payer: Health Management Network Commercial |
$436.05
|
| Rate for Payer: Humana Medicare |
$157.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$323.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$261.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$157.28
|
| Rate for Payer: MDX Hawaii PPO |
$497.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$173.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$157.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$96.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$157.28
|
| Rate for Payer: University Health Alliance Commercial |
$373.93
|
|
|
NUSHIELD NO-1440
|
Facility
|
IP
|
$2,850.00
|
|
|
Service Code
|
HCPCS Q4160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,422.50 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
|
|
NUSHIELD NO-1440
|
Facility
|
OP
|
$2,850.00
|
|
|
Service Code
|
HCPCS Q4160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.01 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: AlohaCare Medicaid |
$147.01
|
| Rate for Payer: AlohaCare Medicare |
$147.01
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Devoted Health Medicare |
$161.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$530.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$183.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$530.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,707.50
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Humana Medicare |
$147.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,795.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,453.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.01
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$161.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,710.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.01
|
| Rate for Payer: University Health Alliance Commercial |
$2,077.36
|
|
|
NXGN GH 14MM 00-5964-050-14
|
Facility
|
IP
|
$2,803.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.68 |
| Max. Negotiated Rate |
$2,718.91 |
| Rate for Payer: Cash Price |
$1,681.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,962.10
|
| Rate for Payer: Health Management Network Commercial |
$2,382.55
|
| Rate for Payer: MDX Hawaii PPO |
$2,718.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.68
|
|
|
NXGN GH 14MM 00-5964-050-14
|
Facility
|
OP
|
$2,803.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,429.53 |
| Max. Negotiated Rate |
$2,718.91 |
| Rate for Payer: Cash Price |
$1,681.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,962.10
|
| Rate for Payer: Health Management Network Commercial |
$2,382.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,765.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,429.53
|
| Rate for Payer: MDX Hawaii PPO |
$2,718.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.68
|
|
|
NXGN PATEL 32MM 00-5972-066-32
|
Facility
|
IP
|
$3,288.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,841.28 |
| Max. Negotiated Rate |
$3,189.36 |
| Rate for Payer: Cash Price |
$1,972.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,301.60
|
| Rate for Payer: Health Management Network Commercial |
$2,794.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,189.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,841.28
|
|
|
NXGN PATEL 32MM 00-5972-066-32
|
Facility
|
OP
|
$3,288.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,676.88 |
| Max. Negotiated Rate |
$3,189.36 |
| Rate for Payer: Cash Price |
$1,972.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,301.60
|
| Rate for Payer: Health Management Network Commercial |
$2,794.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,071.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,676.88
|
| Rate for Payer: MDX Hawaii PPO |
$3,189.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,841.28
|
|
|
NXGN PATEL 35MM 00-5972-066-35
|
Facility
|
IP
|
$3,288.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,841.28 |
| Max. Negotiated Rate |
$3,189.36 |
| Rate for Payer: Cash Price |
$1,972.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,301.60
|
| Rate for Payer: Health Management Network Commercial |
$2,794.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,189.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,841.28
|
|
|
NXGN PATEL 35MM 00-5972-066-35
|
Facility
|
OP
|
$3,288.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,676.88 |
| Max. Negotiated Rate |
$3,189.36 |
| Rate for Payer: Cash Price |
$1,972.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,301.60
|
| Rate for Payer: Health Management Network Commercial |
$2,794.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,071.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,676.88
|
| Rate for Payer: MDX Hawaii PPO |
$3,189.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,841.28
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 00713067815
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.62 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM [5749]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 00713067815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
NDC 72578008901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.09 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 45802004835
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
NDC 72578008901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT [5750]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 45802004835
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.62 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 68308015215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
NDC 00574200815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 68308015215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$336.00
|
|
|
Service Code
|
NDC 00574200802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.36 |
| Max. Negotiated Rate |
$325.92 |
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$319.20
|
| Rate for Payer: Health Management Network Commercial |
$285.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$211.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$171.36
|
| Rate for Payer: MDX Hawaii PPO |
$325.92
|
| Rate for Payer: University Health Alliance Commercial |
$244.91
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
NDC 00574200815
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.47 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.15
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: University Health Alliance Commercial |
$70.70
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
NDC 00574200802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$285.60 |
| Max. Negotiated Rate |
$325.92 |
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Health Management Network Commercial |
$285.60
|
| Rate for Payer: MDX Hawaii PPO |
$325.92
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 66689003799
|
|
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
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 00121086802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60687080017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 00121086802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
