|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC
|
Facility
|
IP
|
$36,074.44
|
|
|
Service Code
|
MSDRG 740
|
| Min. Negotiated Rate |
$36,074.44 |
| Max. Negotiated Rate |
$36,074.44 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36,074.44
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC
|
Facility
|
IP
|
$37,496.56
|
|
|
Service Code
|
MSDRG 739
|
| Min. Negotiated Rate |
$37,496.56 |
| Max. Negotiated Rate |
$37,496.56 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,496.56
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$25,835.18
|
|
|
Service Code
|
MSDRG 741
|
| Min. Negotiated Rate |
$25,835.18 |
| Max. Negotiated Rate |
$25,835.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$25,835.18
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC
|
Facility
|
IP
|
$45,626.35
|
|
|
Service Code
|
MSDRG 737
|
| Min. Negotiated Rate |
$45,626.35 |
| Max. Negotiated Rate |
$45,626.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45,626.35
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC
|
Facility
|
IP
|
$45,626.35
|
|
|
Service Code
|
MSDRG 736
|
| Min. Negotiated Rate |
$45,626.35 |
| Max. Negotiated Rate |
$45,626.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45,626.35
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$45,626.35
|
|
|
Service Code
|
MSDRG 738
|
| Min. Negotiated Rate |
$45,626.35 |
| Max. Negotiated Rate |
$45,626.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45,626.35
|
|
|
UTERINE MANIPULATOR
|
Facility
|
IP
|
$568.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$482.80 |
| Max. Negotiated Rate |
$550.96 |
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Health Management Network Commercial |
$482.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$511.20
|
| Rate for Payer: MDX Hawaii PPO |
$550.96
|
|
|
UTERINE MANIPULATOR
|
Facility
|
OP
|
$568.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$284.00 |
| Max. Negotiated Rate |
$550.96 |
| Rate for Payer: AlohaCare Medicaid |
$284.00
|
| Rate for Payer: AlohaCare Medicare |
$431.68
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Devoted Health Medicare |
$477.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$431.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$539.60
|
| Rate for Payer: Health Management Network Commercial |
$482.80
|
| Rate for Payer: Humana Medicare |
$431.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$511.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$289.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$431.68
|
| Rate for Payer: MDX Hawaii PPO |
$550.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$431.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$431.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$431.68
|
| Rate for Payer: University Health Alliance Commercial |
$414.02
|
|
|
VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$26,451.43
|
|
|
Service Code
|
MSDRG 746
|
| Min. Negotiated Rate |
$26,451.43 |
| Max. Negotiated Rate |
$26,451.43 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,451.43
|
|
|
VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$26,451.43
|
|
|
Service Code
|
MSDRG 747
|
| Min. Negotiated Rate |
$26,451.43 |
| Max. Negotiated Rate |
$26,451.43 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,451.43
|
|
|
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C
|
Facility
|
IP
|
$12,490.95
|
|
|
Service Code
|
MSDRG 768
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$12,490.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,490.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC
|
Facility
|
IP
|
$10,120.75
|
|
|
Service Code
|
MSDRG 806
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$10,120.75 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,120.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC
|
Facility
|
IP
|
$10,120.75
|
|
|
Service Code
|
MSDRG 805
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$10,120.75 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,120.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC
|
Facility
|
IP
|
$9,125.27
|
|
|
Service Code
|
MSDRG 807
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$9,125.27 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9,125.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC
|
Facility
|
IP
|
$14,695.24
|
|
|
Service Code
|
MSDRG 797
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$14,695.24 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,695.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC
|
Facility
|
IP
|
$14,695.24
|
|
|
Service Code
|
MSDRG 796
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$14,695.24 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,695.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC
|
Facility
|
IP
|
$14,695.24
|
|
|
Service Code
|
MSDRG 798
|
| Min. Negotiated Rate |
$7,300.00 |
| Max. Negotiated Rate |
$14,695.24 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,695.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,300.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,760.00
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 50268078915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084030911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084030911
|
|
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: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084030921
|
|
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: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 50268078915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
VALACYCLOVIR 1 GRAM TABLET [13132]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084030921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 68084021521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
VALACYCLOVIR 500 MG TABLET [13133]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 68084021511
|
|
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
|
|
