|
TENO BIO-COMP AR-1662BCC-7
|
Facility
|
IP
|
$1,866.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.96 |
| Max. Negotiated Rate |
$1,810.02 |
| Rate for Payer: Cash Price |
$1,119.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,306.20
|
| Rate for Payer: Health Management Network Commercial |
$1,586.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,679.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,810.02
|
| Rate for Payer: University Health Alliance Commercial |
$1,044.96
|
|
|
TENO BIO-COMP AR-1662BCC-7
|
Facility
|
OP
|
$1,866.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.00 |
| Max. Negotiated Rate |
$1,810.02 |
| Rate for Payer: AlohaCare Medicaid |
$933.00
|
| Rate for Payer: AlohaCare Medicare |
$1,418.16
|
| Rate for Payer: Cash Price |
$1,119.60
|
| Rate for Payer: Devoted Health Medicare |
$1,567.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,418.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,306.20
|
| Rate for Payer: Health Management Network Commercial |
$1,586.10
|
| Rate for Payer: Humana Medicare |
$1,418.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,679.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$951.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,418.16
|
| Rate for Payer: MDX Hawaii PPO |
$1,810.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,418.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,418.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,418.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,044.96
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 50268076411
|
|
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: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 59746038306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50268076411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 59746038306
|
|
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: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 59746038406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 59746038406
|
|
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: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 59746038506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 50268076615
|
|
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: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 59746038506
|
|
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: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 50268076615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J3105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$45.60
|
| Rate for Payer: AlohaCare Medicare |
$12.92
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$12.92
|
| Rate for Payer: Humana Medicare |
$45.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.60
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J3105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$51,883.68
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$51,883.68 |
| Max. Negotiated Rate |
$51,883.68 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,883.68
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$36,714.40
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$36,714.40 |
| Max. Negotiated Rate |
$36,714.40 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36,714.40
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [126226]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS J1071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [126226]
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS J1071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: AlohaCare Medicaid |
$29.00
|
| Rate for Payer: AlohaCare Medicaid |
$36.00
|
| Rate for Payer: AlohaCare Medicare |
$54.72
|
| Rate for Payer: AlohaCare Medicare |
$44.08
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Devoted Health Medicare |
$60.48
|
| Rate for Payer: Devoted Health Medicare |
$48.72
|
| 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 |
$44.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.72
|
| 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 |
$68.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Humana Medicare |
$54.72
|
| Rate for Payer: Humana Medicare |
$44.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.08
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.72
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
| Rate for Payer: University Health Alliance Commercial |
$52.48
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [203772]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS 90714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [203772]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 90714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$95.76
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$105.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$95.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.76
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.76
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [180686]
|
Facility
|
IP
|
$1,169.00
|
|
|
Service Code
|
HCPCS J1670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$993.65 |
| Max. Negotiated Rate |
$1,133.93 |
| Rate for Payer: Cash Price |
$701.40
|
| Rate for Payer: Health Management Network Commercial |
$993.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,052.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,133.93
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [180686]
|
Facility
|
OP
|
$1,169.00
|
|
|
Service Code
|
HCPCS J1670
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$577.05 |
| Max. Negotiated Rate |
$1,133.93 |
| Rate for Payer: AlohaCare Medicaid |
$584.50
|
| Rate for Payer: AlohaCare Medicare |
$888.44
|
| Rate for Payer: Cash Price |
$701.40
|
| Rate for Payer: Cash Price |
$701.40
|
| Rate for Payer: Devoted Health Medicare |
$981.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$577.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$697.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$888.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$577.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,110.55
|
| Rate for Payer: Health Management Network Commercial |
$993.65
|
| Rate for Payer: Humana Medicare |
$888.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,052.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$596.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$888.44
|
| Rate for Payer: MDX Hawaii PPO |
$1,133.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$888.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$888.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$701.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$888.44
|
| Rate for Payer: University Health Alliance Commercial |
$852.08
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [204866]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
NDC 00065074114
|
|
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: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [204866]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
NDC 00065074114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.50 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicare |
$44.84
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$49.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Humana Medicare |
$44.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.84
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.84
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
TETRAHYDROZOLINE 0.05 % EYE DROPS [7800]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00536121794
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
