|
Cholesterol FSI
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
HCPCS 82465
|
| Hospital Charge Code |
8117882
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: Cash Price |
$39.65
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
|
|
Chromosome Analysis, Whole Blood FSI
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
HCPCS 88230
|
| Hospital Charge Code |
12351214
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$143.65 |
| Max. Negotiated Rate |
$163.93 |
| Rate for Payer: Cash Price |
$109.85
|
| Rate for Payer: Health Management Network Commercial |
$143.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.10
|
| Rate for Payer: MDX Hawaii PPO |
$163.93
|
|
|
Chromosome Analysis, Whole Blood FSI
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
HCPCS 88230
|
| Hospital Charge Code |
12351214
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$301.12 |
| Rate for Payer: AlohaCare Medicaid |
$84.50
|
| Rate for Payer: AlohaCare Medicare |
$84.50
|
| Rate for Payer: Cash Price |
$109.85
|
| Rate for Payer: Cash Price |
$109.85
|
| Rate for Payer: Devoted Health Medicare |
$92.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$161.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$145.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$169.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.49
|
| Rate for Payer: Health Management Network Commercial |
$143.65
|
| Rate for Payer: Humana Medicare |
$84.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.50
|
| Rate for Payer: MDX Hawaii PPO |
$163.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$161.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.50
|
| Rate for Payer: University Health Alliance Commercial |
$301.12
|
|
|
CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS
|
Facility
|
OP
|
$7,085.00
|
|
|
Service Code
|
CPT 58350
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$7,085.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,030.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,085.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$849.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC
|
Facility
|
IP
|
$19,886.88
|
|
|
Service Code
|
MSDRG 191
|
| Min. Negotiated Rate |
$19,886.88 |
| Max. Negotiated Rate |
$19,886.88 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,886.88
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC
|
Facility
|
IP
|
$19,886.88
|
|
|
Service Code
|
MSDRG 190
|
| Min. Negotiated Rate |
$19,886.88 |
| Max. Negotiated Rate |
$19,886.88 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,886.88
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$19,886.88
|
|
|
Service Code
|
MSDRG 192
|
| Min. Negotiated Rate |
$19,886.88 |
| Max. Negotiated Rate |
$19,886.88 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,886.88
|
|
|
ciprofloxacin 400 mg/200 mL-D5W premix [HHSC]
|
Facility
|
IP
|
$26.69
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
2500178
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.69 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.93
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cash Price |
$18.79
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: Health Management Network Commercial |
$13.12
|
| Rate for Payer: Health Management Network Commercial |
$15.84
|
| Rate for Payer: Health Management Network Commercial |
$19.52
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Health Management Network Commercial |
$24.57
|
| Rate for Payer: Health Management Network Commercial |
$42.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.67
|
| Rate for Payer: MDX Hawaii PPO |
$22.28
|
| Rate for Payer: MDX Hawaii PPO |
$49.01
|
| Rate for Payer: MDX Hawaii PPO |
$28.04
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$14.97
|
| Rate for Payer: MDX Hawaii PPO |
$18.07
|
|
|
ciprofloxacin 400 mg/200 mL-D5W premix [HHSC]
|
Facility
|
OP
|
$15.43
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
2500178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: AlohaCare Medicaid |
$7.71
|
| Rate for Payer: AlohaCare Medicaid |
$9.31
|
| Rate for Payer: AlohaCare Medicaid |
$11.48
|
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicaid |
$25.27
|
| Rate for Payer: AlohaCare Medicaid |
$14.46
|
| Rate for Payer: AlohaCare Medicare |
$11.48
|
| Rate for Payer: AlohaCare Medicare |
$25.27
|
| Rate for Payer: AlohaCare Medicare |
$9.31
|
| Rate for Payer: AlohaCare Medicare |
$14.46
|
| Rate for Payer: AlohaCare Medicare |
$7.71
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: Cash Price |
$14.93
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cash Price |
$32.84
|
| Rate for Payer: Cash Price |
$18.79
|
| Rate for Payer: Cash Price |
$18.79
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.93
|
| Rate for Payer: Devoted Health Medicare |
$10.25
|
| Rate for Payer: Devoted Health Medicare |
$27.79
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$12.63
|
| Rate for Payer: Devoted Health Medicare |
$8.49
|
| Rate for Payer: Devoted Health Medicare |
$15.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.70
|
| Rate for Payer: Health Management Network Commercial |
$42.95
|
| Rate for Payer: Health Management Network Commercial |
$15.84
|
| Rate for Payer: Health Management Network Commercial |
$24.57
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Health Management Network Commercial |
$13.12
|
| Rate for Payer: Health Management Network Commercial |
$19.52
|
| Rate for Payer: Humana Medicare |
$9.31
|
| Rate for Payer: Humana Medicare |
$25.27
|
| Rate for Payer: Humana Medicare |
$7.71
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Humana Medicare |
$11.48
|
| Rate for Payer: Humana Medicare |
$14.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.27
|
| Rate for Payer: MDX Hawaii PPO |
$49.01
|
| Rate for Payer: MDX Hawaii PPO |
$14.97
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$28.04
|
| Rate for Payer: MDX Hawaii PPO |
$18.07
|
| Rate for Payer: MDX Hawaii PPO |
$22.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: University Health Alliance Commercial |
$11.25
|
| Rate for Payer: University Health Alliance Commercial |
$19.45
|
| Rate for Payer: University Health Alliance Commercial |
$21.07
|
| Rate for Payer: University Health Alliance Commercial |
$36.83
|
| Rate for Payer: University Health Alliance Commercial |
$16.74
|
| Rate for Payer: University Health Alliance Commercial |
$13.58
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904708361
|
| Hospital Charge Code |
2500179
|
|
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
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904724361
|
| Hospital Charge Code |
2500179
|
|
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
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904637861
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
NDC 68084007001
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Health Management Network Commercial |
$15.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.90
|
| Rate for Payer: MDX Hawaii PPO |
$17.14
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904724361
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$17.67
|
|
|
Service Code
|
NDC 68084007001
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: AlohaCare Medicaid |
$8.84
|
| Rate for Payer: AlohaCare Medicare |
$8.84
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.79
|
| Rate for Payer: Health Management Network Commercial |
$15.02
|
| Rate for Payer: Humana Medicare |
$8.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.84
|
| Rate for Payer: MDX Hawaii PPO |
$17.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.84
|
| Rate for Payer: University Health Alliance Commercial |
$12.88
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904637861
|
| Hospital Charge Code |
2500179
|
|
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
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904708361
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$28.87
|
|
|
Service Code
|
NDC 55111012701
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.54 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Cash Price |
$18.77
|
| Rate for Payer: Health Management Network Commercial |
$24.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.98
|
| Rate for Payer: MDX Hawaii PPO |
$28.00
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$28.87
|
|
|
Service Code
|
NDC 55111012701
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AlohaCare Medicaid |
$14.44
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$18.77
|
| Rate for Payer: Devoted Health Medicare |
$15.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.43
|
| Rate for Payer: Health Management Network Commercial |
$24.54
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$28.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$21.04
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$31.06
|
|
|
Service Code
|
NDC 65862007701
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: Cash Price |
$20.19
|
| Rate for Payer: Health Management Network Commercial |
$26.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.95
|
| Rate for Payer: MDX Hawaii PPO |
$30.13
|
|
|
ciprofloxacin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$31.06
|
|
|
Service Code
|
NDC 65862007701
|
| Hospital Charge Code |
2500179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.53 |
| Max. Negotiated Rate |
$30.13 |
| Rate for Payer: AlohaCare Medicaid |
$15.53
|
| Rate for Payer: AlohaCare Medicare |
$15.53
|
| Rate for Payer: Cash Price |
$20.19
|
| Rate for Payer: Devoted Health Medicare |
$17.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.51
|
| Rate for Payer: Health Management Network Commercial |
$26.40
|
| Rate for Payer: Humana Medicare |
$15.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.53
|
| Rate for Payer: MDX Hawaii PPO |
$30.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.53
|
| Rate for Payer: University Health Alliance Commercial |
$22.64
|
|
|
CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC
|
Facility
|
IP
|
$36,714.24
|
|
|
Service Code
|
MSDRG 286
|
| Min. Negotiated Rate |
$36,714.24 |
| Max. Negotiated Rate |
$36,714.24 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36,714.24
|
|
|
CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC
|
Facility
|
IP
|
$32,328.93
|
|
|
Service Code
|
MSDRG 287
|
| Min. Negotiated Rate |
$32,328.93 |
| Max. Negotiated Rate |
$32,328.93 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,328.93
|
|
|
Circumcision
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
12480401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$5,655.00 |
| Rate for Payer: AlohaCare Medicaid |
$672.48
|
| Rate for Payer: AlohaCare Medicare |
$200.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Devoted Health Medicare |
$220.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,655.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$200.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$380.00
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Humana Medicare |
$200.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$204.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$200.00
|
| Rate for Payer: MDX Hawaii PPO |
$388.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$200.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$200.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$200.00
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
Circumcision
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
12486399
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$82.76 |
| Max. Negotiated Rate |
$317.90 |
| Rate for Payer: AlohaCare Medicaid |
$94.88
|
| Rate for Payer: AlohaCare Medicare |
$82.76
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Cash Price |
$243.10
|
| Rate for Payer: Devoted Health Medicare |
$91.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$160.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.10
|
| Rate for Payer: Health Management Network Commercial |
$317.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.76
|
| Rate for Payer: University Health Alliance Commercial |
$126.42
|
|
