|
Radiologic examination, knee; 3 views
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS 73562
|
| Hospital Charge Code |
424735629
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$28.60
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
Radiologic examination, knee; complete, 4 or more views
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 73564
|
| Hospital Charge Code |
424735649
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$154.38 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicare |
$21.42
|
| Rate for Payer: AlohaCare Medicare |
$20.16
|
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$46.92
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$44.16
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Devoted Health Medicare |
$21.42
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$22.13
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$22.13
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Humana Medicare |
$20.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.16
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.42
|
| Rate for Payer: University Health Alliance Commercial |
$77.64
|
| Rate for Payer: University Health Alliance Commercial |
$77.64
|
|
|
Radiologic examination, knee; complete, 4 or more views
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 73564
|
| Hospital Charge Code |
424735649
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
Radiologic examination; lower extremity, infant, minimum of 2 views
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 73592
|
| Hospital Charge Code |
424735929
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
|
|
Radiologic examination; lower extremity, infant, minimum of 2 views
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 73592
|
| Hospital Charge Code |
424735929
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$15.54
|
| Rate for Payer: AlohaCare Medicare |
$14.28
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$22.10
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.04
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$31.28
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$15.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Humana Medicare |
$14.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.54
|
| Rate for Payer: University Health Alliance Commercial |
$56.28
|
| Rate for Payer: University Health Alliance Commercial |
$56.28
|
|
|
Radiologic examination; tibia and fibula, 2 views
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
424735909
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$16.80
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$36.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$34.96
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$18.46
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$18.46
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$16.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$56.98
|
| Rate for Payer: University Health Alliance Commercial |
$56.98
|
|
|
Radiologic examination; tibia and fibula, 2 views
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 73590
|
| Hospital Charge Code |
424735909
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
Radiologic examination; toe(s), minimum of 2 views
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS 73660
|
| Hospital Charge Code |
424736609
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
Radiologic examination; toe(s), minimum of 2 views
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS 73660
|
| Hospital Charge Code |
424736609
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$128.51 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$12.60
|
| Rate for Payer: AlohaCare Medicare |
$11.76
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$27.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$25.76
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.91
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$12.60
|
| Rate for Payer: Humana Medicare |
$11.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.76
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.60
|
| Rate for Payer: University Health Alliance Commercial |
$53.35
|
| Rate for Payer: University Health Alliance Commercial |
$53.35
|
|
|
RADIOTHERAPY
|
Facility
|
IP
|
$17,373.57
|
|
|
Service Code
|
MSDRG 849
|
| Min. Negotiated Rate |
$17,373.57 |
| Max. Negotiated Rate |
$17,373.57 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17,373.57
|
|
|
raloxifene 60 mg Tab [KMC]
|
Facility
|
OP
|
$28.51
|
|
|
Service Code
|
NDC 43598050530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: AlohaCare Medicaid |
$14.26
|
| Rate for Payer: AlohaCare Medicare |
$11.97
|
| Rate for Payer: Cash Price |
$18.53
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$26.23
|
| Rate for Payer: Devoted Health Medicare |
$11.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.08
|
| Rate for Payer: Health Management Network Commercial |
$24.23
|
| Rate for Payer: Humana Medicare |
$11.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.97
|
| Rate for Payer: MDX Hawaii PPO |
$27.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.97
|
| Rate for Payer: University Health Alliance Commercial |
$20.78
|
|
|
raloxifene 60 mg Tab [KMC]
|
Facility
|
IP
|
$28.51
|
|
|
Service Code
|
NDC 43598050530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.23 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Cash Price |
$18.53
|
| Rate for Payer: Health Management Network Commercial |
$24.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.66
|
| Rate for Payer: MDX Hawaii PPO |
$27.65
|
|
|
raltegravir 400 mg Tab [KMC]
|
Facility
|
IP
|
$95.48
|
|
|
Service Code
|
NDC 00006022761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.16 |
| Max. Negotiated Rate |
$92.62 |
| Rate for Payer: Cash Price |
$62.06
|
| Rate for Payer: Health Management Network Commercial |
$81.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.93
|
| Rate for Payer: MDX Hawaii PPO |
$92.62
|
|
|
raltegravir 400 mg Tab [KMC]
|
Facility
|
OP
|
$95.48
|
|
|
Service Code
|
NDC 00006022761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.10 |
| Max. Negotiated Rate |
$92.62 |
| Rate for Payer: AlohaCare Medicaid |
$47.74
|
| Rate for Payer: AlohaCare Medicare |
$40.10
|
| Rate for Payer: Cash Price |
$62.06
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$87.84
|
| Rate for Payer: Devoted Health Medicare |
$40.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.71
|
| Rate for Payer: Health Management Network Commercial |
$81.16
|
| Rate for Payer: Humana Medicare |
$40.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.10
|
| Rate for Payer: MDX Hawaii PPO |
$92.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.10
|
| Rate for Payer: University Health Alliance Commercial |
$69.60
|
|
|
raltegravir 600 mg Tab [KMC]
|
Facility
|
OP
|
$166.66
|
|
|
Service Code
|
NDC 00006308001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$161.66 |
| Rate for Payer: AlohaCare Medicaid |
$83.33
|
| Rate for Payer: AlohaCare Medicare |
$70.00
|
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$153.33
|
| Rate for Payer: Devoted Health Medicare |
$70.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.33
|
| Rate for Payer: Health Management Network Commercial |
$141.66
|
| Rate for Payer: Humana Medicare |
$70.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.00
|
| Rate for Payer: MDX Hawaii PPO |
$161.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.00
|
| Rate for Payer: University Health Alliance Commercial |
$121.48
|
|
|
raltegravir 600 mg Tab [KMC]
|
Facility
|
IP
|
$166.66
|
|
|
Service Code
|
NDC 00006308001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$161.66 |
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Health Management Network Commercial |
$141.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.99
|
| Rate for Payer: MDX Hawaii PPO |
$161.66
|
|
|
ramelteon 8 mg Tab [KMC]
|
Facility
|
OP
|
$55.96
|
|
|
Service Code
|
NDC 52817023530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: AlohaCare Medicaid |
$27.98
|
| Rate for Payer: AlohaCare Medicare |
$23.50
|
| Rate for Payer: Cash Price |
$36.37
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$51.48
|
| Rate for Payer: Devoted Health Medicare |
$23.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.16
|
| Rate for Payer: Health Management Network Commercial |
$47.57
|
| Rate for Payer: Humana Medicare |
$23.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.50
|
| Rate for Payer: MDX Hawaii PPO |
$54.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.50
|
| Rate for Payer: University Health Alliance Commercial |
$40.79
|
|
|
ramelteon 8 mg Tab [KMC]
|
Facility
|
IP
|
$55.96
|
|
|
Service Code
|
NDC 52817023530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.57 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Cash Price |
$36.37
|
| Rate for Payer: Health Management Network Commercial |
$47.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.36
|
| Rate for Payer: MDX Hawaii PPO |
$54.28
|
|
|
ranitidine 150 mg Tab [KMC]
|
Facility
|
OP
|
$6.34
|
|
|
Service Code
|
NDC 51079087920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: AlohaCare Medicaid |
$3.17
|
| Rate for Payer: AlohaCare Medicare |
$2.66
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$5.83
|
| Rate for Payer: Devoted Health Medicare |
$2.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.02
|
| Rate for Payer: Health Management Network Commercial |
$5.39
|
| Rate for Payer: Humana Medicare |
$2.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.66
|
| Rate for Payer: MDX Hawaii PPO |
$6.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.66
|
| Rate for Payer: University Health Alliance Commercial |
$4.62
|
|
|
ranitidine 150 mg Tab [KMC]
|
Facility
|
IP
|
$6.34
|
|
|
Service Code
|
NDC 51079087920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Health Management Network Commercial |
$5.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.71
|
| Rate for Payer: MDX Hawaii PPO |
$6.15
|
|
|
ranolazine 1000 mg ER [KMC]
|
Facility
|
OP
|
$32.26
|
|
|
Service Code
|
NDC 61958100401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.55 |
| Max. Negotiated Rate |
$31.29 |
| Rate for Payer: AlohaCare Medicaid |
$16.13
|
| Rate for Payer: AlohaCare Medicare |
$13.55
|
| Rate for Payer: Cash Price |
$20.97
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$29.68
|
| Rate for Payer: Devoted Health Medicare |
$13.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.65
|
| Rate for Payer: Health Management Network Commercial |
$27.42
|
| Rate for Payer: Humana Medicare |
$13.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.55
|
| Rate for Payer: MDX Hawaii PPO |
$31.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.55
|
| Rate for Payer: University Health Alliance Commercial |
$23.51
|
|
|
ranolazine 1000 mg ER [KMC]
|
Facility
|
IP
|
$32.26
|
|
|
Service Code
|
NDC 61958100401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.42 |
| Max. Negotiated Rate |
$31.29 |
| Rate for Payer: Cash Price |
$20.97
|
| Rate for Payer: Health Management Network Commercial |
$27.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.03
|
| Rate for Payer: MDX Hawaii PPO |
$31.29
|
|
|
ranolazine 500 mg ER Tab [KMC]
|
Facility
|
OP
|
$28.45
|
|
|
Service Code
|
NDC 63304001760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: AlohaCare Medicaid |
$14.22
|
| Rate for Payer: AlohaCare Medicare |
$11.95
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$26.17
|
| Rate for Payer: Devoted Health Medicare |
$11.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.03
|
| Rate for Payer: Health Management Network Commercial |
$24.18
|
| Rate for Payer: Humana Medicare |
$11.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.95
|
| Rate for Payer: MDX Hawaii PPO |
$27.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.95
|
| Rate for Payer: University Health Alliance Commercial |
$20.74
|
|
|
ranolazine 500 mg ER Tab [KMC]
|
Facility
|
IP
|
$28.45
|
|
|
Service Code
|
NDC 63304001760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Management Network Commercial |
$24.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.61
|
| Rate for Payer: MDX Hawaii PPO |
$27.60
|
|
|
RA (Rheumatoid Factor) DLS
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
HCPCS 86431
|
| Hospital Charge Code |
422864315
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Cash Price |
$33.80
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.80
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
|
