|
MICRA VR2 SINGLE CHAMBER
|
Facility
|
IP
|
$22,820.00
|
|
|
Service Code
|
HCPCS C1786
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$12,779.20 |
| Max. Negotiated Rate |
$22,135.40 |
| Rate for Payer: Cash Price |
$13,692.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,974.00
|
| Rate for Payer: Health Management Network Commercial |
$19,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$22,135.40
|
| Rate for Payer: University Health Alliance Commercial |
$12,779.20
|
|
|
MICRA VR2 SINGLE CHAMBER
|
Facility
|
OP
|
$22,820.00
|
|
|
Service Code
|
HCPCS C1786
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$7,074.20 |
| Max. Negotiated Rate |
$22,135.40 |
| Rate for Payer: AlohaCare Medicaid |
$11,410.00
|
| Rate for Payer: AlohaCare Medicare |
$7,074.20
|
| Rate for Payer: Cash Price |
$13,692.00
|
| Rate for Payer: Devoted Health Medicare |
$7,758.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,074.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,974.00
|
| Rate for Payer: Health Management Network Commercial |
$19,397.00
|
| Rate for Payer: Humana Medicare |
$7,074.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,538.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11,638.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,074.20
|
| Rate for Payer: MDX Hawaii PPO |
$22,135.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,074.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,074.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,074.20
|
| Rate for Payer: University Health Alliance Commercial |
$12,779.20
|
|
|
MICROMATRIX MD 500MG MM0500
|
Facility
|
IP
|
$2,419.00
|
|
|
Service Code
|
HCPCS Q4118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,056.15 |
| Max. Negotiated Rate |
$2,346.43 |
| Rate for Payer: Cash Price |
$1,451.40
|
| Rate for Payer: Health Management Network Commercial |
$2,056.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,177.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,346.43
|
|
|
MICROMATRIX MD 500MG MM0500
|
Facility
|
OP
|
$2,419.00
|
|
|
Service Code
|
HCPCS Q4118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$2,346.43 |
| Rate for Payer: AlohaCare Medicaid |
$1,209.50
|
| Rate for Payer: AlohaCare Medicare |
$749.89
|
| Rate for Payer: Cash Price |
$1,451.40
|
| Rate for Payer: Cash Price |
$1,451.40
|
| Rate for Payer: Devoted Health Medicare |
$822.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$749.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,298.05
|
| Rate for Payer: Health Management Network Commercial |
$2,056.15
|
| Rate for Payer: Humana Medicare |
$749.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,177.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,233.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$749.89
|
| Rate for Payer: MDX Hawaii PPO |
$2,346.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$749.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$749.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,451.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$749.89
|
| Rate for Payer: University Health Alliance Commercial |
$1,763.21
|
|
|
MICRO OCD UNIVERSAL DRILL
|
Facility
|
IP
|
$1,526.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,297.10 |
| Max. Negotiated Rate |
$1,480.22 |
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Health Management Network Commercial |
$1,297.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,373.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,480.22
|
|
|
MICRO OCD UNIVERSAL DRILL
|
Facility
|
OP
|
$1,526.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$473.06 |
| Max. Negotiated Rate |
$1,480.22 |
| Rate for Payer: AlohaCare Medicaid |
$763.00
|
| Rate for Payer: AlohaCare Medicare |
$473.06
|
| Rate for Payer: Cash Price |
$915.60
|
| Rate for Payer: Devoted Health Medicare |
$518.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$473.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,449.70
|
| Rate for Payer: Health Management Network Commercial |
$1,297.10
|
| Rate for Payer: Humana Medicare |
$473.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,373.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$778.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$473.06
|
| Rate for Payer: MDX Hawaii PPO |
$1,480.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$473.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$473.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$473.06
|
| Rate for Payer: University Health Alliance Commercial |
$1,112.30
|
|
|
MICROWAVE ABILATION APP 14CM
|
Facility
|
IP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,950.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
|
|
MICROWAVE ABILATION APP 14CM
|
Facility
|
OP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,170.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,500.00
|
| Rate for Payer: AlohaCare Medicare |
$2,170.00
|
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Devoted Health Medicare |
$2,380.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,170.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,650.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Humana Medicare |
$2,170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,570.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,170.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,170.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,170.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,170.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,102.30
|
|
|
MICROWAVE ABILATION APP 19CM
|
Facility
|
OP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,170.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,500.00
|
| Rate for Payer: AlohaCare Medicare |
$2,170.00
|
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Devoted Health Medicare |
$2,380.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,170.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,650.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Humana Medicare |
$2,170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,570.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,170.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,170.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,170.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,170.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,102.30
|
|
|
MICROWAVE ABILATION APP 19CM
|
Facility
|
IP
|
$7,000.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,950.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
MIDAZOLAM 1 MG/ML INJECTION SOLUTION [93519]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68094076262
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$376.00
|
|
|
Service Code
|
NDC 00054356699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.56 |
| Max. Negotiated Rate |
$364.72 |
| Rate for Payer: AlohaCare Medicaid |
$188.00
|
| Rate for Payer: AlohaCare Medicare |
$116.56
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Devoted Health Medicare |
$127.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$116.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$357.20
|
| Rate for Payer: Health Management Network Commercial |
$319.60
|
| Rate for Payer: Humana Medicare |
$116.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$338.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$191.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$116.56
|
| Rate for Payer: MDX Hawaii PPO |
$364.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$116.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$116.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$116.56
|
| Rate for Payer: University Health Alliance Commercial |
$274.07
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68094076259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68094076262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
IP
|
$376.00
|
|
|
Service Code
|
NDC 00054356699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$319.60 |
| Max. Negotiated Rate |
$364.72 |
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Health Management Network Commercial |
$319.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$338.40
|
| Rate for Payer: MDX Hawaii PPO |
$364.72
|
|
|
MIDAZOLAM 2 MG/ML ORAL SYRUP [24176]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68094076259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION [93520]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J2251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: AlohaCare Medicaid |
$57.00
|
| Rate for Payer: AlohaCare Medicare |
$35.34
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Devoted Health Medicare |
$38.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Humana Medicare |
$35.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.34
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.34
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
|
|
MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [162718]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J2251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION [168904]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION [168902]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
