|
Benzodiazepine, Urine Screen FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1,176.40 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
|
|
benzonatate 100 mg capsule [HHSC]
|
Facility
|
OP
|
$4.05
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
2500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: AlohaCare Medicaid |
$2.02
|
| Rate for Payer: AlohaCare Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Devoted Health Medicare |
$2.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.85
|
| Rate for Payer: Health Management Network Commercial |
$3.44
|
| Rate for Payer: Humana Medicare |
$2.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.02
|
| Rate for Payer: University Health Alliance Commercial |
$2.95
|
|
|
benzonatate 100 mg capsule [HHSC]
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 60687034601
|
| Hospital Charge Code |
2500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Health Management Network Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.65
|
| Rate for Payer: MDX Hawaii PPO |
$3.93
|
|
|
benzonatate 100 mg capsule [HHSC]
|
Facility
|
OP
|
$4.05
|
|
|
Service Code
|
NDC 60687034601
|
| Hospital Charge Code |
2500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: AlohaCare Medicaid |
$2.02
|
| Rate for Payer: AlohaCare Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Devoted Health Medicare |
$2.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.85
|
| Rate for Payer: Health Management Network Commercial |
$3.44
|
| Rate for Payer: Humana Medicare |
$2.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.02
|
| Rate for Payer: University Health Alliance Commercial |
$2.95
|
|
|
benzonatate 100 mg capsule [HHSC]
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
2500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Health Management Network Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.65
|
| Rate for Payer: MDX Hawaii PPO |
$3.93
|
|
|
benztropine 1 mg tablet [HHSC]
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
2500107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
|
|
benztropine 1 mg tablet [HHSC]
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 60687036801
|
| Hospital Charge Code |
2500107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: AlohaCare Medicaid |
$1.64
|
| Rate for Payer: AlohaCare Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Devoted Health Medicare |
$1.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.11
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Humana Medicare |
$1.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.64
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.64
|
| Rate for Payer: University Health Alliance Commercial |
$2.38
|
|
|
benztropine 1 mg tablet [HHSC]
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 60687036801
|
| Hospital Charge Code |
2500107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
|
|
benztropine 1 mg tablet [HHSC]
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 68084038801
|
| Hospital Charge Code |
2500107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: AlohaCare Medicaid |
$1.64
|
| Rate for Payer: AlohaCare Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Devoted Health Medicare |
$1.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.11
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Humana Medicare |
$1.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.64
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.64
|
| Rate for Payer: University Health Alliance Commercial |
$2.38
|
|
|
benztropine 2mg/2mL ampule [HHSC]
|
Facility
|
IP
|
$330.11
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
2500108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$280.59 |
| Max. Negotiated Rate |
$320.21 |
| Rate for Payer: Cash Price |
$214.57
|
| Rate for Payer: Cash Price |
$200.08
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Health Management Network Commercial |
$307.22
|
| Rate for Payer: Health Management Network Commercial |
$261.64
|
| Rate for Payer: Health Management Network Commercial |
$280.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$325.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$277.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.10
|
| Rate for Payer: MDX Hawaii PPO |
$320.21
|
| Rate for Payer: MDX Hawaii PPO |
$298.58
|
| Rate for Payer: MDX Hawaii PPO |
$350.59
|
|
|
benztropine 2mg/2mL ampule [HHSC]
|
Facility
|
OP
|
$330.11
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
2500108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$320.21 |
| Rate for Payer: AlohaCare Medicaid |
$165.06
|
| Rate for Payer: AlohaCare Medicaid |
$180.72
|
| Rate for Payer: AlohaCare Medicaid |
$153.91
|
| Rate for Payer: AlohaCare Medicare |
$180.72
|
| Rate for Payer: AlohaCare Medicare |
$153.91
|
| Rate for Payer: AlohaCare Medicare |
$165.06
|
| Rate for Payer: Cash Price |
$200.08
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$200.08
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$214.57
|
| Rate for Payer: Cash Price |
$214.57
|
| Rate for Payer: Devoted Health Medicare |
$198.79
|
| Rate for Payer: Devoted Health Medicare |
$181.56
|
| Rate for Payer: Devoted Health Medicare |
$169.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$165.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$180.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$343.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$292.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$313.60
|
| Rate for Payer: Health Management Network Commercial |
$261.64
|
| Rate for Payer: Health Management Network Commercial |
$280.59
|
| Rate for Payer: Health Management Network Commercial |
$307.22
|
| Rate for Payer: Humana Medicare |
$165.06
|
| Rate for Payer: Humana Medicare |
$153.91
|
| Rate for Payer: Humana Medicare |
$180.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$325.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$277.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$168.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$184.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$156.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$180.72
|
| Rate for Payer: MDX Hawaii PPO |
$350.59
|
| Rate for Payer: MDX Hawaii PPO |
$298.58
|
| Rate for Payer: MDX Hawaii PPO |
$320.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$165.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$180.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$180.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$165.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$184.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$198.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$216.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$180.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$165.06
|
| Rate for Payer: University Health Alliance Commercial |
$263.45
|
| Rate for Payer: University Health Alliance Commercial |
$240.62
|
| Rate for Payer: University Health Alliance Commercial |
$224.36
|
|
|
Beta HCG Quantitative FSI
|
Facility
|
OP
|
$572.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
8117856
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$554.84 |
| Rate for Payer: AlohaCare Medicaid |
$286.00
|
| Rate for Payer: AlohaCare Medicare |
$286.00
|
| Rate for Payer: Cash Price |
$371.80
|
| Rate for Payer: Cash Price |
$371.80
|
| Rate for Payer: Devoted Health Medicare |
$314.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$286.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.05
|
| Rate for Payer: Health Management Network Commercial |
$486.20
|
| Rate for Payer: Humana Medicare |
$286.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$514.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$291.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$286.00
|
| Rate for Payer: MDX Hawaii PPO |
$554.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$286.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$286.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$286.00
|
| Rate for Payer: University Health Alliance Commercial |
$38.91
|
|
|
Beta HCG Quantitative FSI
|
Facility
|
IP
|
$572.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
8117856
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$486.20 |
| Max. Negotiated Rate |
$554.84 |
| Rate for Payer: Cash Price |
$371.80
|
| Rate for Payer: Health Management Network Commercial |
$486.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$514.80
|
| Rate for Payer: MDX Hawaii PPO |
$554.84
|
|
|
Beta-Hydroxybutyrate FSI
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8228842
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$60.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Devoted Health Medicare |
$66.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.17
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$60.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.13
|
|
|
Beta-Hydroxybutyrate FSI
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8228842
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
betamethasone ac-sp 6mg/ml vial [HHSC]
|
Facility
|
OP
|
$218.79
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
2500111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$212.23 |
| Rate for Payer: AlohaCare Medicaid |
$109.39
|
| Rate for Payer: AlohaCare Medicaid |
$165.12
|
| Rate for Payer: AlohaCare Medicaid |
$107.47
|
| Rate for Payer: AlohaCare Medicaid |
$89.56
|
| Rate for Payer: AlohaCare Medicare |
$89.56
|
| Rate for Payer: AlohaCare Medicare |
$107.47
|
| Rate for Payer: AlohaCare Medicare |
$109.39
|
| Rate for Payer: AlohaCare Medicare |
$165.12
|
| Rate for Payer: Cash Price |
$116.43
|
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Cash Price |
$139.70
|
| Rate for Payer: Cash Price |
$139.70
|
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Cash Price |
$214.66
|
| Rate for Payer: Cash Price |
$116.43
|
| Rate for Payer: Cash Price |
$214.66
|
| Rate for Payer: Devoted Health Medicare |
$118.21
|
| Rate for Payer: Devoted Health Medicare |
$120.33
|
| Rate for Payer: Devoted Health Medicare |
$98.52
|
| Rate for Payer: Devoted Health Medicare |
$181.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$165.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$204.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$313.74
|
| Rate for Payer: Health Management Network Commercial |
$280.71
|
| Rate for Payer: Health Management Network Commercial |
$182.69
|
| Rate for Payer: Health Management Network Commercial |
$152.25
|
| Rate for Payer: Health Management Network Commercial |
$185.97
|
| Rate for Payer: Humana Medicare |
$107.47
|
| Rate for Payer: Humana Medicare |
$89.56
|
| Rate for Payer: Humana Medicare |
$109.39
|
| Rate for Payer: Humana Medicare |
$165.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$168.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.56
|
| Rate for Payer: MDX Hawaii PPO |
$320.34
|
| Rate for Payer: MDX Hawaii PPO |
$212.23
|
| Rate for Payer: MDX Hawaii PPO |
$208.48
|
| Rate for Payer: MDX Hawaii PPO |
$173.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$165.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$165.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$128.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$131.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$198.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$165.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.56
|
| Rate for Payer: University Health Alliance Commercial |
$240.72
|
| Rate for Payer: University Health Alliance Commercial |
$159.48
|
| Rate for Payer: University Health Alliance Commercial |
$130.56
|
| Rate for Payer: University Health Alliance Commercial |
$156.66
|
|
|
betamethasone ac-sp 6mg/ml vial [HHSC]
|
Facility
|
IP
|
$214.93
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
2500111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.69 |
| Max. Negotiated Rate |
$208.48 |
| Rate for Payer: Cash Price |
$139.70
|
| Rate for Payer: Cash Price |
$116.43
|
| Rate for Payer: Cash Price |
$214.66
|
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Health Management Network Commercial |
$152.25
|
| Rate for Payer: Health Management Network Commercial |
$182.69
|
| Rate for Payer: Health Management Network Commercial |
$185.97
|
| Rate for Payer: Health Management Network Commercial |
$280.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.44
|
| Rate for Payer: MDX Hawaii PPO |
$173.75
|
| Rate for Payer: MDX Hawaii PPO |
$212.23
|
| Rate for Payer: MDX Hawaii PPO |
$320.34
|
| Rate for Payer: MDX Hawaii PPO |
$208.48
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
OP
|
$390.80
|
|
|
Service Code
|
NDC 00472037945
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$195.40 |
| Max. Negotiated Rate |
$379.08 |
| Rate for Payer: Cash Price |
$254.02
|
| Rate for Payer: Devoted Health Medicare |
$214.94
|
| Rate for Payer: AlohaCare Medicaid |
$195.40
|
| Rate for Payer: AlohaCare Medicare |
$195.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$195.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$371.26
|
| Rate for Payer: Health Management Network Commercial |
$332.18
|
| Rate for Payer: Humana Medicare |
$195.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$351.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$195.40
|
| Rate for Payer: MDX Hawaii PPO |
$379.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$195.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$195.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$234.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$195.40
|
| Rate for Payer: University Health Alliance Commercial |
$284.85
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
IP
|
$390.80
|
|
|
Service Code
|
NDC 00472037945
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$332.18 |
| Max. Negotiated Rate |
$379.08 |
| Rate for Payer: Cash Price |
$254.02
|
| Rate for Payer: Health Management Network Commercial |
$332.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$351.72
|
| Rate for Payer: MDX Hawaii PPO |
$379.08
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
OP
|
$494.91
|
|
|
Service Code
|
NDC 68462029855
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$247.46 |
| Max. Negotiated Rate |
$480.06 |
| Rate for Payer: AlohaCare Medicaid |
$247.46
|
| Rate for Payer: AlohaCare Medicare |
$247.46
|
| Rate for Payer: Cash Price |
$321.69
|
| Rate for Payer: Devoted Health Medicare |
$272.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$247.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$470.16
|
| Rate for Payer: Health Management Network Commercial |
$420.67
|
| Rate for Payer: Humana Medicare |
$247.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$252.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$247.46
|
| Rate for Payer: MDX Hawaii PPO |
$480.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$247.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$247.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$296.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$247.46
|
| Rate for Payer: University Health Alliance Commercial |
$360.74
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
OP
|
$200.23
|
|
|
Service Code
|
NDC 00168025846
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.11 |
| Max. Negotiated Rate |
$194.22 |
| Rate for Payer: AlohaCare Medicaid |
$100.11
|
| Rate for Payer: AlohaCare Medicare |
$100.11
|
| Rate for Payer: Cash Price |
$130.15
|
| Rate for Payer: Devoted Health Medicare |
$110.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.22
|
| Rate for Payer: Health Management Network Commercial |
$170.20
|
| Rate for Payer: Humana Medicare |
$100.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.11
|
| Rate for Payer: MDX Hawaii PPO |
$194.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.11
|
| Rate for Payer: University Health Alliance Commercial |
$145.95
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
IP
|
$494.91
|
|
|
Service Code
|
NDC 68462029855
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$420.67 |
| Max. Negotiated Rate |
$480.06 |
| Rate for Payer: Cash Price |
$321.69
|
| Rate for Payer: Health Management Network Commercial |
$420.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.42
|
| Rate for Payer: MDX Hawaii PPO |
$480.06
|
|
|
betamethasone-clotrimazole 0.05%-1% topical cream [HHSC]
|
Facility
|
IP
|
$200.23
|
|
|
Service Code
|
NDC 00168025846
|
| Hospital Charge Code |
2500113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.20 |
| Max. Negotiated Rate |
$194.22 |
| Rate for Payer: Cash Price |
$130.15
|
| Rate for Payer: Health Management Network Commercial |
$170.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.21
|
| Rate for Payer: MDX Hawaii PPO |
$194.22
|
|
|
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC
|
Facility
|
IP
|
$71,337.81
|
|
|
Service Code
|
MSDRG 461
|
| Min. Negotiated Rate |
$71,337.81 |
| Max. Negotiated Rate |
$71,337.81 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,337.81
|
|
|
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC
|
Facility
|
IP
|
$71,337.81
|
|
|
Service Code
|
MSDRG 462
|
| Min. Negotiated Rate |
$71,337.81 |
| Max. Negotiated Rate |
$71,337.81 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,337.81
|
|
