|
IMPLAN TYMPANOST W/TAB 1.14
|
Facility
|
IP
|
$126.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: University Health Alliance Commercial |
$70.56
|
|
|
IMPLAN WEIGHT EYELID 1.4G
|
Facility
|
OP
|
$1,218.00
|
|
|
Service Code
|
HCPCS L8610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$44.09 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: AlohaCare Medicaid |
$609.00
|
| Rate for Payer: AlohaCare Medicare |
$377.58
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Devoted Health Medicare |
$414.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$377.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$852.60
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Humana Medicare |
$377.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$621.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$377.58
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$377.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$377.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$377.58
|
| Rate for Payer: University Health Alliance Commercial |
$682.08
|
|
|
IMPLAN WEIGHT EYELID 1.4G
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
HCPCS L8610
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$682.08 |
| Max. Negotiated Rate |
$1,181.46 |
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$852.60
|
| Rate for Payer: Health Management Network Commercial |
$1,035.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,096.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,181.46
|
| Rate for Payer: University Health Alliance Commercial |
$682.08
|
|
|
IMPRESS BERENSTEIN 5FX125
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
|
|
IMPRESS BERENSTEIN 5FX125
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS C1887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.45 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicare |
$60.45
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Devoted Health Medicare |
$66.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Humana Medicare |
$60.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.45
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.45
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
|
|
INBORN AND OTHER DISORDERS OF METABOLISM
|
Facility
|
IP
|
$85,327.20
|
|
|
Service Code
|
MSDRG 642
|
| Min. Negotiated Rate |
$85,327.20 |
| Max. Negotiated Rate |
$85,327.20 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$85,327.20
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [10265]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
NDC 00517037505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Management Network Commercial |
$816.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$864.00
|
| Rate for Payer: MDX Hawaii PPO |
$931.20
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [187932]
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C9300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$223.20 |
| Max. Negotiated Rate |
$698.40 |
| Rate for Payer: AlohaCare Medicaid |
$360.00
|
| Rate for Payer: AlohaCare Medicare |
$223.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Devoted Health Medicare |
$244.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$223.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$684.00
|
| Rate for Payer: Health Management Network Commercial |
$612.00
|
| Rate for Payer: Humana Medicare |
$223.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$648.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$367.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$223.20
|
| Rate for Payer: MDX Hawaii PPO |
$698.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$223.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$223.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$432.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$223.20
|
| Rate for Payer: University Health Alliance Commercial |
$524.81
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [187932]
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C9300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$612.00 |
| Max. Negotiated Rate |
$698.40 |
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Health Management Network Commercial |
$612.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$648.00
|
| Rate for Payer: MDX Hawaii PPO |
$698.40
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
NDC 70100082502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$455.60 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$482.40
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
NDC 70100042402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$229.80
|
| 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
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$383.00
|
|
|
Service Code
|
NDC 70100042401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.55 |
| Max. Negotiated Rate |
$371.51 |
| Rate for Payer: Cash Price |
$229.80
|
| 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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 50268043015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 68462040601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 50268043015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 50268043011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 68462040601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 50268043011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$619.00
|
|
|
Service Code
|
NDC 70710185207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$526.15 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.10
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
|
