|
ACETIC ACID 2 % EAR SOLUTION [17801]
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
NDC 52817081615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$127.68
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$141.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Humana Medicare |
$127.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.68
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.68
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
ACETIC ACID 5% 1 GAL [4080288]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 00004080071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [132335]
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
NDC 24208053920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$228.92 |
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [132335]
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
NDC 24208053920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.00 |
| Max. Negotiated Rate |
$228.92 |
| Rate for Payer: AlohaCare Medicaid |
$118.00
|
| Rate for Payer: AlohaCare Medicare |
$179.36
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Devoted Health Medicare |
$198.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$179.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$224.20
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Humana Medicare |
$179.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$179.36
|
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$179.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$179.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$179.36
|
| Rate for Payer: University Health Alliance Commercial |
$172.02
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.40 |
| Max. Negotiated Rate |
$217.28 |
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Health Management Network Commercial |
$128.35
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Health Management Network Commercial |
$193.80
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$205.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.90
|
| Rate for Payer: MDX Hawaii PPO |
$221.16
|
| Rate for Payer: MDX Hawaii PPO |
$217.28
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: MDX Hawaii PPO |
$146.47
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$221.16 |
| Rate for Payer: AlohaCare Medicaid |
$114.00
|
| Rate for Payer: AlohaCare Medicaid |
$75.50
|
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicaid |
$105.00
|
| Rate for Payer: AlohaCare Medicaid |
$112.00
|
| Rate for Payer: AlohaCare Medicare |
$114.76
|
| Rate for Payer: AlohaCare Medicare |
$170.24
|
| Rate for Payer: AlohaCare Medicare |
$173.28
|
| Rate for Payer: AlohaCare Medicare |
$159.60
|
| Rate for Payer: AlohaCare Medicare |
$58.52
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Devoted Health Medicare |
$64.68
|
| Rate for Payer: Devoted Health Medicare |
$191.52
|
| Rate for Payer: Devoted Health Medicare |
$176.40
|
| Rate for Payer: Devoted Health Medicare |
$188.16
|
| Rate for Payer: Devoted Health Medicare |
$126.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$170.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$159.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$173.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$212.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$199.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$216.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$143.45
|
| Rate for Payer: Health Management Network Commercial |
$193.80
|
| Rate for Payer: Health Management Network Commercial |
$128.35
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$170.24
|
| Rate for Payer: Humana Medicare |
$159.60
|
| Rate for Payer: Humana Medicare |
$114.76
|
| Rate for Payer: Humana Medicare |
$58.52
|
| Rate for Payer: Humana Medicare |
$173.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$205.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$116.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$159.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$170.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$173.28
|
| Rate for Payer: MDX Hawaii PPO |
$221.16
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
| Rate for Payer: MDX Hawaii PPO |
$217.28
|
| Rate for Payer: MDX Hawaii PPO |
$146.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$173.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$170.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$159.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$170.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$173.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$159.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$126.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$90.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$136.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$134.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$173.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$170.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$159.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.52
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
| Rate for Payer: University Health Alliance Commercial |
$153.07
|
| Rate for Payer: University Health Alliance Commercial |
$110.06
|
| Rate for Payer: University Health Alliance Commercial |
$166.19
|
| Rate for Payer: University Health Alliance Commercial |
$163.27
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.67 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
ACHILLES TENDON BIOCLN 453042
|
Facility
|
OP
|
$6,070.00
|
|
|
Service Code
|
HCPCS C1716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$641.96 |
| Max. Negotiated Rate |
$5,887.90 |
| Rate for Payer: AlohaCare Medicaid |
$3,035.00
|
| Rate for Payer: AlohaCare Medicare |
$4,613.20
|
| Rate for Payer: Cash Price |
$3,642.00
|
| Rate for Payer: Cash Price |
$3,642.00
|
| Rate for Payer: Devoted Health Medicare |
$5,098.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$641.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,613.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,249.00
|
| Rate for Payer: Health Management Network Commercial |
$5,159.50
|
| Rate for Payer: Humana Medicare |
$4,613.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,463.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,095.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,613.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,887.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,613.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,613.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$651.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,613.20
|
| Rate for Payer: University Health Alliance Commercial |
$3,399.20
|
|
|
ACHILLES TENDON BIOCLN 453042
|
Facility
|
IP
|
$6,070.00
|
|
|
Service Code
|
HCPCS C1716
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,399.20 |
| Max. Negotiated Rate |
$5,887.90 |
| Rate for Payer: Cash Price |
$3,642.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,249.00
|
| Rate for Payer: Health Management Network Commercial |
$5,159.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,463.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,887.90
|
| Rate for Payer: University Health Alliance Commercial |
$3,399.20
|
|
|
ACL THIGHTROPE II AR-1588RT-2J
|
Facility
|
OP
|
$1,709.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$854.50 |
| Max. Negotiated Rate |
$1,657.73 |
| Rate for Payer: AlohaCare Medicaid |
$854.50
|
| Rate for Payer: AlohaCare Medicare |
$1,298.84
|
| Rate for Payer: Cash Price |
$1,025.40
|
| Rate for Payer: Devoted Health Medicare |
$1,435.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,298.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,196.30
|
| Rate for Payer: Health Management Network Commercial |
$1,452.65
|
| Rate for Payer: Humana Medicare |
$1,298.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,538.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$871.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,298.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,657.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,298.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,298.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,298.84
|
| Rate for Payer: University Health Alliance Commercial |
$957.04
|
|
|
ACL THIGHTROPE II AR-1588RT-2J
|
Facility
|
IP
|
$1,709.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.04 |
| Max. Negotiated Rate |
$1,657.73 |
| Rate for Payer: Cash Price |
$1,025.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,196.30
|
| Rate for Payer: Health Management Network Commercial |
$1,452.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,538.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,657.73
|
| Rate for Payer: University Health Alliance Commercial |
$957.04
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [202413]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 66689020204
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: AlohaCare Medicaid |
$37.50
|
| Rate for Payer: AlohaCare Medicare |
$57.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.25
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Humana Medicare |
$57.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.00
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.00
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [202413]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 66689020204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [27099]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 00574052176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [27099]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 00574052176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$45.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Humana Medicare |
$45.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.60
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
ACUITY CORONARY EXTEN HOOK 9F
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$866.50 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$1,317.08
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$1,455.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,317.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,646.35
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$1,317.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,317.08
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,317.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,317.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,317.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,263.18
|
|
|
ACUITY CORONARY EXTEN HOOK 9F
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,473.05 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
|
|
ACUITY CORONARY HOOK 9F
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$866.50 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$1,317.08
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$1,455.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,317.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,646.35
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$1,317.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,317.08
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,317.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,317.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,317.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,263.18
|
|
|
ACUITY CORONARY HOOK 9F
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,473.05 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
|
|
ACUITY CORONARY SINUS 7F IC130
|
Facility
|
IP
|
$919.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.15 |
| Max. Negotiated Rate |
$891.43 |
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Health Management Network Commercial |
$781.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$827.10
|
| Rate for Payer: MDX Hawaii PPO |
$891.43
|
|
|
ACUITY CORONARY SINUS 7F IC130
|
Facility
|
OP
|
$919.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$459.50 |
| Max. Negotiated Rate |
$891.43 |
| Rate for Payer: AlohaCare Medicaid |
$459.50
|
| Rate for Payer: AlohaCare Medicare |
$698.44
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Devoted Health Medicare |
$771.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$698.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$873.05
|
| Rate for Payer: Health Management Network Commercial |
$781.15
|
| Rate for Payer: Humana Medicare |
$698.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$827.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$468.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$698.44
|
| Rate for Payer: MDX Hawaii PPO |
$891.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$698.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$698.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$698.44
|
| Rate for Payer: University Health Alliance Commercial |
$669.86
|
|
|
ACUITY CORONARY SINUS 7F IC90
|
Facility
|
IP
|
$919.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$781.15 |
| Max. Negotiated Rate |
$891.43 |
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Health Management Network Commercial |
$781.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$827.10
|
| Rate for Payer: MDX Hawaii PPO |
$891.43
|
|
|
ACUITY CORONARY SINUS 7F IC90
|
Facility
|
OP
|
$919.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$459.50 |
| Max. Negotiated Rate |
$891.43 |
| Rate for Payer: AlohaCare Medicaid |
$459.50
|
| Rate for Payer: AlohaCare Medicare |
$698.44
|
| Rate for Payer: Cash Price |
$551.40
|
| Rate for Payer: Devoted Health Medicare |
$771.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$698.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$873.05
|
| Rate for Payer: Health Management Network Commercial |
$781.15
|
| Rate for Payer: Humana Medicare |
$698.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$827.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$468.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$698.44
|
| Rate for Payer: MDX Hawaii PPO |
$891.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$698.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$698.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$698.44
|
| Rate for Payer: University Health Alliance Commercial |
$669.86
|
|
|
ACUITY CORONARY WIDE 9F
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$866.50 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$1,317.08
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$1,455.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,317.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,646.35
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$1,317.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,317.08
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,317.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,317.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,317.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,263.18
|
|
