|
docusate-senna 50 mg-8.6 mg Tab [KMC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687062201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.76
|
| Rate for Payer: Devoted Health Medicare |
$1.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.26
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.26
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
docusate-senna 50 mg-8.6 mg Tab [KMC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687062201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
docusate sodium 100 mg/10 mL Oral Liq [KMC]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 63739097610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Health Management Network Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.55
|
| Rate for Payer: MDX Hawaii PPO |
$0.59
|
|
|
docusate sodium 100 mg/10 mL Oral Liq [KMC]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 63739097610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: AlohaCare Medicaid |
$0.31
|
| Rate for Payer: AlohaCare Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$0.56
|
| Rate for Payer: Devoted Health Medicare |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.58
|
| Rate for Payer: Health Management Network Commercial |
$0.52
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.26
|
| Rate for Payer: MDX Hawaii PPO |
$0.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.26
|
| Rate for Payer: University Health Alliance Commercial |
$0.44
|
|
|
docusate sodium 100 mg Cap [KMC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.76
|
| Rate for Payer: Devoted Health Medicare |
$1.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.26
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.26
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
docusate sodium 100 mg Cap [KMC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
docusate sodium 250 mg Oral Cap [KMC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 48433010101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.76
|
| Rate for Payer: Devoted Health Medicare |
$1.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.26
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.26
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
docusate sodium 250 mg Oral Cap [KMC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 48433010101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
dolutegravir 50 mg Tab [KMC]
|
Facility
|
OP
|
$321.82
|
|
|
Service Code
|
NDC 49702022813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.16 |
| Max. Negotiated Rate |
$312.17 |
| Rate for Payer: AlohaCare Medicaid |
$160.91
|
| Rate for Payer: AlohaCare Medicare |
$135.16
|
| Rate for Payer: Cash Price |
$209.18
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$296.07
|
| Rate for Payer: Devoted Health Medicare |
$135.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$135.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$305.73
|
| Rate for Payer: Health Management Network Commercial |
$273.55
|
| Rate for Payer: Humana Medicare |
$135.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$289.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$164.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$135.16
|
| Rate for Payer: MDX Hawaii PPO |
$312.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$135.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$193.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$135.16
|
| Rate for Payer: University Health Alliance Commercial |
$234.57
|
|
|
dolutegravir 50 mg Tab [KMC]
|
Facility
|
IP
|
$321.82
|
|
|
Service Code
|
NDC 49702022813
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.55 |
| Max. Negotiated Rate |
$312.17 |
| Rate for Payer: Cash Price |
$209.18
|
| Rate for Payer: Health Management Network Commercial |
$273.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$289.64
|
| Rate for Payer: MDX Hawaii PPO |
$312.17
|
|
|
dolutegravir-lamivudine 50 mg-300 mg Tab [KMC]
|
Facility
|
IP
|
$495.31
|
|
|
Service Code
|
NDC 49702024633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$421.01 |
| Max. Negotiated Rate |
$480.45 |
| Rate for Payer: Cash Price |
$321.95
|
| Rate for Payer: Health Management Network Commercial |
$421.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.78
|
| Rate for Payer: MDX Hawaii PPO |
$480.45
|
|
|
dolutegravir-lamivudine 50 mg-300 mg Tab [KMC]
|
Facility
|
OP
|
$495.31
|
|
|
Service Code
|
NDC 49702024633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$208.03 |
| Max. Negotiated Rate |
$480.45 |
| Rate for Payer: AlohaCare Medicaid |
$247.66
|
| Rate for Payer: AlohaCare Medicare |
$208.03
|
| Rate for Payer: Cash Price |
$321.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$455.69
|
| Rate for Payer: Devoted Health Medicare |
$208.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$208.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$470.54
|
| Rate for Payer: Health Management Network Commercial |
$421.01
|
| Rate for Payer: Humana Medicare |
$208.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$252.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$208.03
|
| Rate for Payer: MDX Hawaii PPO |
$480.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$208.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$208.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$297.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$208.03
|
| Rate for Payer: University Health Alliance Commercial |
$361.03
|
|
|
donepezil 23 mg Tab [KMC]
|
Facility
|
IP
|
$41.65
|
|
|
Service Code
|
NDC 24979000406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$40.40 |
| Rate for Payer: Cash Price |
$27.07
|
| Rate for Payer: Health Management Network Commercial |
$35.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.48
|
| Rate for Payer: MDX Hawaii PPO |
$40.40
|
|
|
donepezil 23 mg Tab [KMC]
|
Facility
|
OP
|
$41.65
|
|
|
Service Code
|
NDC 24979000406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.49 |
| Max. Negotiated Rate |
$40.40 |
| Rate for Payer: AlohaCare Medicaid |
$20.82
|
| Rate for Payer: AlohaCare Medicare |
$17.49
|
| Rate for Payer: Cash Price |
$27.07
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$38.32
|
| Rate for Payer: Devoted Health Medicare |
$17.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.57
|
| Rate for Payer: Health Management Network Commercial |
$35.40
|
| Rate for Payer: Humana Medicare |
$17.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.49
|
| Rate for Payer: MDX Hawaii PPO |
$40.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.49
|
| Rate for Payer: University Health Alliance Commercial |
$30.36
|
|
|
donepezil 5 mg Tab [KMC]
|
Facility
|
IP
|
$34.60
|
|
|
Service Code
|
NDC 16571077809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$33.56 |
| Rate for Payer: Cash Price |
$22.49
|
| Rate for Payer: Health Management Network Commercial |
$29.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.14
|
| Rate for Payer: MDX Hawaii PPO |
$33.56
|
|
|
donepezil 5 mg Tab [KMC]
|
Facility
|
OP
|
$34.60
|
|
|
Service Code
|
NDC 16571077809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$33.56 |
| Rate for Payer: AlohaCare Medicaid |
$17.30
|
| Rate for Payer: AlohaCare Medicare |
$14.53
|
| Rate for Payer: Cash Price |
$22.49
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$31.83
|
| Rate for Payer: Devoted Health Medicare |
$14.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.87
|
| Rate for Payer: Health Management Network Commercial |
$29.41
|
| Rate for Payer: Humana Medicare |
$14.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.53
|
| Rate for Payer: MDX Hawaii PPO |
$33.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.53
|
| Rate for Payer: University Health Alliance Commercial |
$25.22
|
|
|
Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 76827
|
| Hospital Charge Code |
424768279
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Health Management Network Commercial |
$99.45
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.30
|
| Rate for Payer: MDX Hawaii PPO |
$113.49
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
|
|
Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS 76827
|
| Hospital Charge Code |
424768279
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$163.30 |
| Rate for Payer: AlohaCare Medicaid |
$58.50
|
| Rate for Payer: AlohaCare Medicaid |
$62.50
|
| Rate for Payer: AlohaCare Medicare |
$52.50
|
| Rate for Payer: AlohaCare Medicare |
$49.14
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$115.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$107.64
|
| Rate for Payer: Devoted Health Medicare |
$49.14
|
| Rate for Payer: Devoted Health Medicare |
$52.50
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$57.41
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$57.41
|
| 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 |
$49.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.50
|
| 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 |
$106.25
|
| Rate for Payer: Health Management Network Commercial |
$99.45
|
| Rate for Payer: Humana Medicare |
$49.14
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.14
|
| Rate for Payer: MDX Hawaii PPO |
$113.49
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.14
|
| Rate for Payer: University Health Alliance Commercial |
$163.30
|
| Rate for Payer: University Health Alliance Commercial |
$163.30
|
|
|
Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 76828
|
| Hospital Charge Code |
424768289
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$154.38 |
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicaid |
$61.00
|
| Rate for Payer: AlohaCare Medicare |
$51.24
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$112.24
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$105.80
|
| Rate for Payer: Devoted Health Medicare |
$48.30
|
| Rate for Payer: Devoted Health Medicare |
$51.24
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$37.31
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$37.31
|
| 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 |
$48.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.24
|
| 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 |
$103.70
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Humana Medicare |
$51.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$118.70
|
| Rate for Payer: University Health Alliance Commercial |
$118.70
|
|
|
Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 76828
|
| Hospital Charge Code |
424768289
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$103.70 |
| Max. Negotiated Rate |
$118.34 |
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
|
|
Doppler velocimetry, fetal; middle cerebral artery
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS 76821
|
| Hospital Charge Code |
424768219
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$51.43 |
| Max. Negotiated Rate |
$202.02 |
| Rate for Payer: AlohaCare Medicaid |
$72.50
|
| Rate for Payer: AlohaCare Medicaid |
$77.50
|
| Rate for Payer: AlohaCare Medicare |
$65.10
|
| Rate for Payer: AlohaCare Medicare |
$60.90
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Cash Price |
$100.75
|
| Rate for Payer: Cash Price |
$100.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$142.60
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$133.40
|
| Rate for Payer: Devoted Health Medicare |
$60.90
|
| Rate for Payer: Devoted Health Medicare |
$65.10
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$51.43
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$51.43
|
| 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 |
$60.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.10
|
| 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 |
$131.75
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Humana Medicare |
$60.90
|
| Rate for Payer: Humana Medicare |
$65.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.90
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.90
|
| Rate for Payer: University Health Alliance Commercial |
$202.02
|
| Rate for Payer: University Health Alliance Commercial |
$202.02
|
|
|
Doppler velocimetry, fetal; middle cerebral artery
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS 76821
|
| Hospital Charge Code |
424768219
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$100.75
|
| Rate for Payer: Cash Price |
$94.25
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
Doppler velocimetry, fetal; umbilical artery
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
424768209
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: Cash Price |
$72.15
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
|
|
Doppler velocimetry, fetal; umbilical artery
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
424768209
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$154.38 |
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicaid |
$55.50
|
| Rate for Payer: AlohaCare Medicare |
$46.62
|
| Rate for Payer: AlohaCare Medicare |
$44.10
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cash Price |
$72.15
|
| Rate for Payer: Cash Price |
$72.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$102.12
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$96.60
|
| Rate for Payer: Devoted Health Medicare |
$44.10
|
| Rate for Payer: Devoted Health Medicare |
$46.62
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$51.43
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$51.43
|
| 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 |
$44.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.62
|
| 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 |
$94.35
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Humana Medicare |
$44.10
|
| Rate for Payer: Humana Medicare |
$46.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.10
|
| Rate for Payer: University Health Alliance Commercial |
$133.24
|
| Rate for Payer: University Health Alliance Commercial |
$133.24
|
|
|
dornase alfa 2.5 mg/2.5 mL Soln [KMC]
|
Facility
|
IP
|
$172.81
|
|
|
Service Code
|
HCPCS J7639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$167.63 |
| Rate for Payer: Cash Price |
$112.33
|
| Rate for Payer: Health Management Network Commercial |
$146.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.53
|
| Rate for Payer: MDX Hawaii PPO |
$167.63
|
|
