|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 50268006115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 50268006115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.64
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.64
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 50268006111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.64
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.64
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 50268006111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$998.00
|
|
|
Service Code
|
NDC 72578008201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$848.30 |
| Max. Negotiated Rate |
$968.06 |
| Rate for Payer: Cash Price |
$598.80
|
| Rate for Payer: Health Management Network Commercial |
$848.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$898.20
|
| Rate for Payer: MDX Hawaii PPO |
$968.06
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$998.00
|
|
|
Service Code
|
NDC 72578008201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$499.00 |
| Max. Negotiated Rate |
$968.06 |
| Rate for Payer: AlohaCare Medicaid |
$499.00
|
| Rate for Payer: AlohaCare Medicare |
$758.48
|
| Rate for Payer: Cash Price |
$598.80
|
| Rate for Payer: Devoted Health Medicare |
$838.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$758.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$948.10
|
| Rate for Payer: Health Management Network Commercial |
$848.30
|
| Rate for Payer: Humana Medicare |
$758.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$898.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$508.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$758.48
|
| Rate for Payer: MDX Hawaii PPO |
$968.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$758.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$758.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$758.48
|
| Rate for Payer: University Health Alliance Commercial |
$727.44
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J0133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Health Management Network Commercial |
$47.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$54.32
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J0133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$28.00
|
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicaid |
$31.50
|
| Rate for Payer: AlohaCare Medicare |
$47.88
|
| Rate for Payer: AlohaCare Medicare |
$111.72
|
| Rate for Payer: AlohaCare Medicare |
$21.28
|
| Rate for Payer: AlohaCare Medicare |
$42.56
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Devoted Health Medicare |
$47.04
|
| Rate for Payer: Devoted Health Medicare |
$23.52
|
| Rate for Payer: Devoted Health Medicare |
$52.92
|
| Rate for Payer: Devoted Health Medicare |
$123.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$47.60
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Humana Medicare |
$111.72
|
| Rate for Payer: Humana Medicare |
$42.56
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Humana Medicare |
$47.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.28
|
| Rate for Payer: MDX Hawaii PPO |
$54.32
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.28
|
| Rate for Payer: University Health Alliance Commercial |
$107.15
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$40.82
|
| Rate for Payer: University Health Alliance Commercial |
$45.92
|
|
|
ADAPTER CARTRIDGE 110030166
|
Facility
|
IP
|
$225.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.25 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
|
|
ADAPTER CARTRIDGE 110030166
|
Facility
|
OP
|
$225.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: AlohaCare Medicaid |
$112.50
|
| Rate for Payer: AlohaCare Medicare |
$171.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Devoted Health Medicare |
$189.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$171.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$213.75
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Humana Medicare |
$171.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$171.00
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$171.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$171.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$171.00
|
| Rate for Payer: University Health Alliance Commercial |
$164.00
|
|
|
ADAPTER FOR ELLIK EVACU 3664
|
Facility
|
OP
|
$348.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$337.56 |
| Rate for Payer: AlohaCare Medicaid |
$174.00
|
| Rate for Payer: AlohaCare Medicare |
$264.48
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Devoted Health Medicare |
$292.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$264.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$330.60
|
| Rate for Payer: Health Management Network Commercial |
$295.80
|
| Rate for Payer: Humana Medicare |
$264.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$313.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$177.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$264.48
|
| Rate for Payer: MDX Hawaii PPO |
$337.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$264.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$264.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$264.48
|
| Rate for Payer: University Health Alliance Commercial |
$253.66
|
|
|
ADAPTER FOR ELLIK EVACU 3664
|
Facility
|
IP
|
$348.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$295.80 |
| Max. Negotiated Rate |
$337.56 |
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Health Management Network Commercial |
$295.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$313.20
|
| Rate for Payer: MDX Hawaii PPO |
$337.56
|
|
|
ADAPTER LATITUDE 3G USB 6295
|
Facility
|
IP
|
$746.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$634.10 |
| Max. Negotiated Rate |
$723.62 |
| Rate for Payer: Cash Price |
$447.60
|
| Rate for Payer: Health Management Network Commercial |
$634.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$671.40
|
| Rate for Payer: MDX Hawaii PPO |
$723.62
|
|
|
ADAPTER LATITUDE 3G USB 6295
|
Facility
|
OP
|
$746.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$373.00 |
| Max. Negotiated Rate |
$723.62 |
| Rate for Payer: AlohaCare Medicaid |
$373.00
|
| Rate for Payer: AlohaCare Medicare |
$566.96
|
| Rate for Payer: Cash Price |
$447.60
|
| Rate for Payer: Devoted Health Medicare |
$626.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$566.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$708.70
|
| Rate for Payer: Health Management Network Commercial |
$634.10
|
| Rate for Payer: Humana Medicare |
$566.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$671.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$380.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$566.96
|
| Rate for Payer: MDX Hawaii PPO |
$723.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$566.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$566.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$566.96
|
| Rate for Payer: University Health Alliance Commercial |
$543.76
|
|
|
ADAPTER S1S HIP NEC STD 431186
|
Facility
|
OP
|
$1,663.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$831.50 |
| Max. Negotiated Rate |
$1,613.11 |
| Rate for Payer: AlohaCare Medicaid |
$831.50
|
| Rate for Payer: AlohaCare Medicare |
$1,263.88
|
| Rate for Payer: Cash Price |
$997.80
|
| Rate for Payer: Devoted Health Medicare |
$1,396.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,263.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,164.10
|
| Rate for Payer: Health Management Network Commercial |
$1,413.55
|
| Rate for Payer: Humana Medicare |
$1,263.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,496.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$848.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,263.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,613.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,263.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,263.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,263.88
|
| Rate for Payer: University Health Alliance Commercial |
$931.28
|
|
|
ADAPTER S1S HIP NEC STD 431186
|
Facility
|
IP
|
$1,663.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$931.28 |
| Max. Negotiated Rate |
$1,613.11 |
| Rate for Payer: Cash Price |
$997.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,164.10
|
| Rate for Payer: Health Management Network Commercial |
$1,413.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,496.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,613.11
|
| Rate for Payer: University Health Alliance Commercial |
$931.28
|
|
|
ADAPTER SLEEVE C-TAPE 19-0325T
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.00 |
| Max. Negotiated Rate |
$744.96 |
| Rate for Payer: AlohaCare Medicaid |
$384.00
|
| Rate for Payer: AlohaCare Medicare |
$583.68
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Devoted Health Medicare |
$645.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$583.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$537.60
|
| Rate for Payer: Health Management Network Commercial |
$652.80
|
| Rate for Payer: Humana Medicare |
$583.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$691.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$391.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$583.68
|
| Rate for Payer: MDX Hawaii PPO |
$744.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$583.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$583.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$583.68
|
| Rate for Payer: University Health Alliance Commercial |
$430.08
|
|
|
ADAPTER SLEEVE C-TAPE 19-0325T
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.08 |
| Max. Negotiated Rate |
$744.96 |
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$537.60
|
| Rate for Payer: Health Management Network Commercial |
$652.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$691.20
|
| Rate for Payer: MDX Hawaii PPO |
$744.96
|
| Rate for Payer: University Health Alliance Commercial |
$430.08
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J0153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [38703]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J0153
|
|
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: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [8975]
|
Facility
|
OP
|
$706.00
|
|
|
Service Code
|
HCPCS J0153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$684.82 |
| Rate for Payer: AlohaCare Medicaid |
$353.00
|
| Rate for Payer: AlohaCare Medicare |
$536.56
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Devoted Health Medicare |
$593.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$536.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$670.70
|
| Rate for Payer: Health Management Network Commercial |
$600.10
|
| Rate for Payer: Humana Medicare |
$536.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$635.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$360.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$536.56
|
| Rate for Payer: MDX Hawaii PPO |
$684.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$536.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$536.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$423.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$536.56
|
| Rate for Payer: University Health Alliance Commercial |
$514.60
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [8975]
|
Facility
|
IP
|
$706.00
|
|
|
Service Code
|
HCPCS J0153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$600.10 |
| Max. Negotiated Rate |
$684.82 |
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Health Management Network Commercial |
$600.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$635.40
|
| Rate for Payer: MDX Hawaii PPO |
$684.82
|
|
|
ADHES LIQUIBAND DOME TIP
|
Facility
|
OP
|
$104.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: AlohaCare Medicaid |
$52.00
|
| Rate for Payer: AlohaCare Medicare |
$79.04
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Devoted Health Medicare |
$87.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.80
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Humana Medicare |
$79.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.04
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.04
|
| Rate for Payer: University Health Alliance Commercial |
$75.81
|
|
|
ADHES LIQUIBAND DOME TIP
|
Facility
|
IP
|
$104.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
|
|
ADOLESCENT TAN 13MM DIA. RIGHT
|
Facility
|
IP
|
$6,776.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,794.56 |
| Max. Negotiated Rate |
$6,572.72 |
| Rate for Payer: Cash Price |
$4,065.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,743.20
|
| Rate for Payer: Health Management Network Commercial |
$5,759.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,098.40
|
| Rate for Payer: MDX Hawaii PPO |
$6,572.72
|
| Rate for Payer: University Health Alliance Commercial |
$3,794.56
|
|
