|
DEBRIDEMENT MUSCLES AND/OR FASCIA <= 20 SQ CM CHAR
|
Facility
|
IP
|
$1,405.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
440110430
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,194.25 |
| Max. Negotiated Rate |
$1,362.85 |
| Rate for Payer: Cash Price |
$913.25
|
| Rate for Payer: Health Management Network Commercial |
$1,194.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,264.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,362.85
|
|
|
DEBRIDEMENT NAIL ANY METHOD 1-5
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
HCPCS 11720
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: AlohaCare Medicaid |
$13.89
|
| Rate for Payer: AlohaCare Medicare |
$12.45
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Devoted Health Medicare |
$12.45
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.74
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.45
|
| Rate for Payer: University Health Alliance Commercial |
$15.40
|
|
|
DEBRIDEMENT NAIL ANY METHOD 6/>
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
HCPCS 11721
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$190.40 |
| Rate for Payer: AlohaCare Medicaid |
$23.31
|
| Rate for Payer: AlohaCare Medicare |
$20.95
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Devoted Health Medicare |
$20.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$23.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.12
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.95
|
| Rate for Payer: University Health Alliance Commercial |
$25.55
|
|
|
DEBRIDEMENT OPEN WOUND FIRST 20 SQ CM/<
|
Professional
|
Both
|
$732.00
|
|
|
Service Code
|
HCPCS 97597
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$30.95 |
| Max. Negotiated Rate |
$622.20 |
| Rate for Payer: AlohaCare Medicaid |
$35.17
|
| Rate for Payer: AlohaCare Medicare |
$30.95
|
| Rate for Payer: Cash Price |
$475.80
|
| Rate for Payer: Cash Price |
$475.80
|
| Rate for Payer: Devoted Health Medicare |
$30.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$35.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$58.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.88
|
| Rate for Payer: Health Management Network Commercial |
$622.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.95
|
| Rate for Payer: University Health Alliance Commercial |
$145.00
|
|
|
DEBRIDEMENT OPN WND EA ADDL 20 SQ CM/PRT THEREOF
|
Professional
|
Both
|
$365.00
|
|
|
Service Code
|
HCPCS 97598
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$21.32 |
| Max. Negotiated Rate |
$310.25 |
| Rate for Payer: AlohaCare Medicaid |
$24.27
|
| Rate for Payer: AlohaCare Medicare |
$21.32
|
| Rate for Payer: Cash Price |
$237.25
|
| Rate for Payer: Cash Price |
$237.25
|
| Rate for Payer: Devoted Health Medicare |
$21.32
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$24.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$72.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.18
|
| Rate for Payer: Health Management Network Commercial |
$310.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.32
|
|
|
DEBRIDEMENT SELECT >20CM Occupational
|
Facility
|
OP
|
$383.00
|
|
|
Service Code
|
HCPCS 97598 GO
|
| Hospital Charge Code |
432975980
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: AlohaCare Medicaid |
$191.50
|
| Rate for Payer: AlohaCare Medicare |
$160.86
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$352.36
|
| Rate for Payer: Devoted Health Medicare |
$160.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$363.85
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: Humana Medicare |
$160.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$344.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$195.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.86
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.86
|
| Rate for Payer: University Health Alliance Commercial |
$279.17
|
|
|
DEBRIDEMENT SELECT >20CM Occupational
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
HCPCS 97598 GO
|
| Hospital Charge Code |
432975980
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$344.70
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
|
|
DEBRIDEMENT SELECT <=20CM Physical
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
HCPCS 97597 GP
|
| Hospital Charge Code |
426975970,
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$653.65 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: Cash Price |
$499.85
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
|
|
DEBRIDEMENT SELECT <=20CM Physical
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
HCPCS 97597 GP
|
| Hospital Charge Code |
426975970,
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$37.07 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: AlohaCare Medicaid |
$384.50
|
| Rate for Payer: AlohaCare Medicare |
$322.98
|
| Rate for Payer: Cash Price |
$499.85
|
| Rate for Payer: Cash Price |
$499.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$707.48
|
| Rate for Payer: Devoted Health Medicare |
$322.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$322.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$730.55
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Humana Medicare |
$322.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$392.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$322.98
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$322.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$322.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$322.98
|
| Rate for Payer: University Health Alliance Commercial |
$560.52
|
|
|
DEBRIDEMENT SELECT >20CM Physical
|
Facility
|
OP
|
$383.00
|
|
|
Service Code
|
HCPCS 97598 GP
|
| Hospital Charge Code |
426975980
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: AlohaCare Medicaid |
$191.50
|
| Rate for Payer: AlohaCare Medicare |
$160.86
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$352.36
|
| Rate for Payer: Devoted Health Medicare |
$160.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$363.85
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: Humana Medicare |
$160.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$344.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$195.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.86
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.86
|
| Rate for Payer: University Health Alliance Commercial |
$279.17
|
|
|
DEBRIDEMENT SELECT >20CM Physical
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
HCPCS 97598 GP
|
| Hospital Charge Code |
426975980
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Health Management Network Commercial |
$325.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$344.70
|
| Rate for Payer: MDX Hawaii PPO |
$371.51
|
|
|
DEBRIDEMENT-SKIN, SUB-Q Charge
|
Facility
|
OP
|
$1,405.00
|
|
|
Service Code
|
HCPCS 11042
|
| Hospital Charge Code |
440110420
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$702.50
|
| Rate for Payer: AlohaCare Medicare |
$590.10
|
| Rate for Payer: Cash Price |
$913.25
|
| Rate for Payer: Cash Price |
$913.25
|
| Rate for Payer: Cash Price |
$913.25
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,292.60
|
| Rate for Payer: Devoted Health Medicare |
$590.10
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$590.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,334.75
|
| Rate for Payer: Health Management Network Commercial |
$1,194.25
|
| Rate for Payer: Humana Medicare |
$590.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,264.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$590.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,362.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$590.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$590.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$590.10
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
DEBRIDEMENT-SKIN, SUB-Q Charge
|
Facility
|
IP
|
$1,405.00
|
|
|
Service Code
|
HCPCS 11042
|
| Hospital Charge Code |
440110420
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,194.25 |
| Max. Negotiated Rate |
$1,362.85 |
| Rate for Payer: Cash Price |
$913.25
|
| Rate for Payer: Health Management Network Commercial |
$1,194.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,264.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,362.85
|
|
|
DEBRIDEMENT SUBCUTANEOUS TISSUE 1ST 20 SQ CM/<
|
Professional
|
Both
|
$1,004.00
|
|
|
Service Code
|
HCPCS 11042
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$56.51 |
| Max. Negotiated Rate |
$853.40 |
| Rate for Payer: AlohaCare Medicaid |
$61.67
|
| Rate for Payer: AlohaCare Medicare |
$56.51
|
| Rate for Payer: Cash Price |
$652.60
|
| Rate for Payer: Cash Price |
$652.60
|
| Rate for Payer: Devoted Health Medicare |
$56.51
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$61.67
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$78.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.16
|
| Rate for Payer: Health Management Network Commercial |
$853.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.51
|
|
|
DEBRIDEMENT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
HCPCS 11045
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$21.52 |
| Max. Negotiated Rate |
$96.05 |
| Rate for Payer: AlohaCare Medicaid |
$24.64
|
| Rate for Payer: AlohaCare Medicare |
$21.52
|
| Rate for Payer: Cash Price |
$73.45
|
| Rate for Payer: Cash Price |
$73.45
|
| Rate for Payer: Devoted Health Medicare |
$21.52
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$24.64
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.52
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.52
|
| Rate for Payer: University Health Alliance Commercial |
$30.72
|
|
|
DEBRIDE NAIL, 1-5 Charge
|
Facility
|
OP
|
$311.00
|
|
|
Service Code
|
HCPCS 11720
|
| Hospital Charge Code |
440117200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$130.62 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$155.50
|
| Rate for Payer: AlohaCare Medicare |
$130.62
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$286.12
|
| Rate for Payer: Devoted Health Medicare |
$130.62
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$130.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$295.45
|
| Rate for Payer: Health Management Network Commercial |
$264.35
|
| Rate for Payer: Humana Medicare |
$130.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$130.62
|
| Rate for Payer: MDX Hawaii PPO |
$301.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$130.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$130.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$130.62
|
| Rate for Payer: University Health Alliance Commercial |
$226.69
|
|
|
DEBRIDE NAIL, 1-5 Charge
|
Facility
|
IP
|
$311.00
|
|
|
Service Code
|
HCPCS 11720
|
| Hospital Charge Code |
440117200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$264.35 |
| Max. Negotiated Rate |
$301.67 |
| Rate for Payer: Cash Price |
$202.15
|
| Rate for Payer: Health Management Network Commercial |
$264.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.90
|
| Rate for Payer: MDX Hawaii PPO |
$301.67
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$25,835.18
|
|
|
Service Code
|
MSDRG 056
|
| Min. Negotiated Rate |
$25,835.18 |
| Max. Negotiated Rate |
$25,835.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$25,835.18
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$25,835.18
|
|
|
Service Code
|
MSDRG 057
|
| Min. Negotiated Rate |
$25,835.18 |
| Max. Negotiated Rate |
$25,835.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$25,835.18
|
|
|
DELIVERY PLACENTA
|
Facility
|
IP
|
$7,021.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
440594140
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,967.85 |
| Max. Negotiated Rate |
$6,810.37 |
| Rate for Payer: Cash Price |
$4,563.65
|
| Rate for Payer: Health Management Network Commercial |
$5,967.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,318.90
|
| Rate for Payer: MDX Hawaii PPO |
$6,810.37
|
|
|
DELIVERY PLACENTA
|
Facility
|
OP
|
$7,021.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
440594140
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$6,810.37 |
| Rate for Payer: AlohaCare Medicaid |
$3,510.50
|
| Rate for Payer: AlohaCare Medicare |
$2,948.82
|
| Rate for Payer: Cash Price |
$4,563.65
|
| Rate for Payer: Cash Price |
$4,563.65
|
| Rate for Payer: Cash Price |
$4,563.65
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$6,459.32
|
| Rate for Payer: Devoted Health Medicare |
$2,948.82
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,948.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,669.95
|
| Rate for Payer: Health Management Network Commercial |
$5,967.85
|
| Rate for Payer: Humana Medicare |
$2,948.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,318.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,948.82
|
| Rate for Payer: MDX Hawaii PPO |
$6,810.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,948.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,948.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,948.82
|
| Rate for Payer: University Health Alliance Commercial |
$5,117.61
|
|
|
demeclocycline 150 mg Tab [KMC]
|
Facility
|
OP
|
$42.53
|
|
|
Service Code
|
NDC 62584015901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: AlohaCare Medicaid |
$21.27
|
| Rate for Payer: AlohaCare Medicare |
$17.86
|
| Rate for Payer: Cash Price |
$27.64
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$39.13
|
| Rate for Payer: Devoted Health Medicare |
$17.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.40
|
| Rate for Payer: Health Management Network Commercial |
$36.15
|
| Rate for Payer: Humana Medicare |
$17.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.86
|
| Rate for Payer: MDX Hawaii PPO |
$41.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.86
|
| Rate for Payer: University Health Alliance Commercial |
$31.00
|
|
|
demeclocycline 150 mg Tab [KMC]
|
Facility
|
IP
|
$42.53
|
|
|
Service Code
|
NDC 62584015901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Cash Price |
$27.64
|
| Rate for Payer: Health Management Network Commercial |
$36.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.28
|
| Rate for Payer: MDX Hawaii PPO |
$41.25
|
|
|
denosumab 60 mg/mL Sol [KMC]
|
Facility
|
IP
|
$9,002.06
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,651.75 |
| Max. Negotiated Rate |
$8,732.00 |
| Rate for Payer: Cash Price |
$5,851.34
|
| Rate for Payer: Health Management Network Commercial |
$7,651.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,101.85
|
| Rate for Payer: MDX Hawaii PPO |
$8,732.00
|
|
|
denosumab 60 mg/mL Sol [KMC]
|
Facility
|
OP
|
$9,002.06
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.24 |
| Max. Negotiated Rate |
$8,732.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,501.03
|
| Rate for Payer: AlohaCare Medicare |
$3,780.87
|
| Rate for Payer: Cash Price |
$5,851.34
|
| Rate for Payer: Cash Price |
$5,851.34
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$8,281.90
|
| Rate for Payer: Devoted Health Medicare |
$3,780.87
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$29.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,780.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,551.96
|
| Rate for Payer: Health Management Network Commercial |
$7,651.75
|
| Rate for Payer: Humana Medicare |
$3,780.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,101.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,591.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,780.87
|
| Rate for Payer: MDX Hawaii PPO |
$8,732.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,780.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,780.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,401.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,780.87
|
| Rate for Payer: University Health Alliance Commercial |
$6,561.60
|
|
