|
HEMOST PARTICLES 3G
|
Facility
|
IP
|
$812.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$690.20 |
| Max. Negotiated Rate |
$787.64 |
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: Health Management Network Commercial |
$690.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$730.80
|
| Rate for Payer: MDX Hawaii PPO |
$787.64
|
|
|
HEMOST SPRAY 10
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,500.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,500.00
|
| Rate for Payer: AlohaCare Medicare |
$3,800.00
|
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Devoted Health Medicare |
$4,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,800.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,750.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Humana Medicare |
$3,800.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,550.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,800.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,800.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,800.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,800.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,644.50
|
|
|
HEMOST SPRAY 10
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,250.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
|
|
HEMOST SPRAY 7
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,500.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,500.00
|
| Rate for Payer: AlohaCare Medicare |
$3,800.00
|
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Devoted Health Medicare |
$4,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,800.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,750.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Humana Medicare |
$3,800.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,550.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,800.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,800.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,800.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,800.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,644.50
|
|
|
HEMOST SPRAY 7
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1052
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,250.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
|
|
HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION [10177]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION [10177]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$24.32
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Humana Medicare |
$24.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.32
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION [10176]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: AlohaCare Medicare |
$12.92
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$12.92
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.92
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV [166269]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS J1644
|
|
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: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV [166269]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$38.76
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$38.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.76
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.76
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION [10181]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV [166266]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| 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 |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| 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
|
|
|
HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV [166266]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J1644
|
|
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
|
|
|
HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION [197315]
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: AlohaCare Medicaid |
$25.00
|
| Rate for Payer: AlohaCare Medicare |
$38.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Devoted Health Medicare |
$42.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.50
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Humana Medicare |
$38.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.00
|
| Rate for Payer: University Health Alliance Commercial |
$36.45
|
|
|
HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION [197315]
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
|
|
HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV [166267]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: UnitedHealthcare Medicare |
$21.28
|
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$17.50
|
| Rate for Payer: AlohaCare Medicare |
$26.60
|
| Rate for Payer: AlohaCare Medicare |
$21.28
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Devoted Health Medicare |
$23.52
|
| Rate for Payer: Devoted Health Medicare |
$29.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.25
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Humana Medicare |
$26.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.60
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.60
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$25.51
|
|
|
HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV [166267]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J1644
|
|
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 |
$21.00
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.50
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [203251]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 90632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE [203251]
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 90632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.61 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: AlohaCare Medicaid |
$77.50
|
| Rate for Payer: AlohaCare Medicare |
$117.80
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Devoted Health Medicare |
$130.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$71.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$71.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$147.25
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Humana Medicare |
$117.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.80
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$117.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.80
|
| Rate for Payer: University Health Alliance Commercial |
$112.98
|
|
|
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE [180688]
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS 90371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.00 |
| Max. Negotiated Rate |
$175.26 |
| Rate for Payer: AlohaCare Medicaid |
$80.00
|
| Rate for Payer: AlohaCare Medicare |
$121.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Devoted Health Medicare |
$134.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$175.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$152.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Humana Medicare |
$121.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.60
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$96.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.60
|
| Rate for Payer: University Health Alliance Commercial |
$116.62
|
|
|
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE [180688]
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS 90371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
HEPATITIS B IMMUNE GLOBULIN > 1,560 UNIT/5 ML INTRAMUSCULAR SOLUTION [91047]
|
Facility
|
IP
|
$1,423.00
|
|
|
Service Code
|
HCPCS 90371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,209.55 |
| Max. Negotiated Rate |
$1,380.31 |
| Rate for Payer: Cash Price |
$853.80
|
| Rate for Payer: Health Management Network Commercial |
$1,209.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,280.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,380.31
|
|
|
HEPATITIS B VIRUS VACCINE RECMB(PF) 5 MCG/0.5 ML INTRAMUSCULAR SYRINGE [187816]
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 00006409302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
|
