|
citric acid-sodium citrate 334 mg-500 mg/5 mL soln 30 mL [HHSC]
|
Facility
|
IP
|
$16.55
|
|
|
Service Code
|
NDC 00121119000
|
| Hospital Charge Code |
2500182
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.07 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Health Management Network Commercial |
$14.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.89
|
| Rate for Payer: MDX Hawaii PPO |
$16.05
|
|
|
CK (CPK) FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 82550
|
| Hospital Charge Code |
8117883
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.51
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$16.84
|
|
|
CK (CPK) FSI
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 82550
|
| Hospital Charge Code |
8117883
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
CKMB FSI
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 82553
|
| Hospital Charge Code |
8228856
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$129.98 |
| Rate for Payer: AlohaCare Medicaid |
$67.00
|
| Rate for Payer: AlohaCare Medicare |
$67.00
|
| Rate for Payer: Cash Price |
$87.10
|
| Rate for Payer: Cash Price |
$87.10
|
| Rate for Payer: Devoted Health Medicare |
$73.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$67.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.55
|
| Rate for Payer: Health Management Network Commercial |
$113.90
|
| Rate for Payer: Humana Medicare |
$67.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.00
|
| Rate for Payer: MDX Hawaii PPO |
$129.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$67.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$67.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$67.00
|
| Rate for Payer: University Health Alliance Commercial |
$29.84
|
|
|
CKMB FSI
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 82553
|
| Hospital Charge Code |
8228856
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$113.90 |
| Max. Negotiated Rate |
$129.98 |
| Rate for Payer: Cash Price |
$87.10
|
| Rate for Payer: Health Management Network Commercial |
$113.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.60
|
| Rate for Payer: MDX Hawaii PPO |
$129.98
|
|
|
CK, (Rfx if Elevated) FSI
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 82550
|
| Hospital Charge Code |
8228855
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
CK, (Rfx if Elevated) FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 82550
|
| Hospital Charge Code |
8228855
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.01
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.51
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$16.84
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$39.56
|
|
|
Service Code
|
NDC 68084065125
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$38.37 |
| Rate for Payer: Cash Price |
$25.71
|
| Rate for Payer: Health Management Network Commercial |
$33.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.60
|
| Rate for Payer: MDX Hawaii PPO |
$38.37
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$38.97
|
|
|
Service Code
|
NDC 65862022660
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.48 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: AlohaCare Medicaid |
$19.48
|
| Rate for Payer: AlohaCare Medicare |
$19.48
|
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Devoted Health Medicare |
$21.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.02
|
| Rate for Payer: Health Management Network Commercial |
$33.12
|
| Rate for Payer: Humana Medicare |
$19.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.48
|
| Rate for Payer: MDX Hawaii PPO |
$37.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.48
|
| Rate for Payer: University Health Alliance Commercial |
$28.41
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$25.14
|
|
|
Service Code
|
NDC 57237004560
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.37 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Health Management Network Commercial |
$21.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.63
|
| Rate for Payer: MDX Hawaii PPO |
$24.39
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$38.97
|
|
|
Service Code
|
NDC 00781196260
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.48 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: AlohaCare Medicaid |
$19.48
|
| Rate for Payer: AlohaCare Medicare |
$19.48
|
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Devoted Health Medicare |
$21.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.02
|
| Rate for Payer: Health Management Network Commercial |
$33.12
|
| Rate for Payer: Humana Medicare |
$19.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.48
|
| Rate for Payer: MDX Hawaii PPO |
$37.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.48
|
| Rate for Payer: University Health Alliance Commercial |
$28.41
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$25.14
|
|
|
Service Code
|
NDC 57237004560
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.57 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: AlohaCare Medicaid |
$12.57
|
| Rate for Payer: AlohaCare Medicare |
$12.57
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Devoted Health Medicare |
$13.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.88
|
| Rate for Payer: Health Management Network Commercial |
$21.37
|
| Rate for Payer: Humana Medicare |
$12.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.57
|
| Rate for Payer: MDX Hawaii PPO |
$24.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.57
|
| Rate for Payer: University Health Alliance Commercial |
$18.32
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$38.97
|
|
|
Service Code
|
NDC 00781196260
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Health Management Network Commercial |
$33.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.07
|
| Rate for Payer: MDX Hawaii PPO |
$37.80
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
IP
|
$38.97
|
|
|
Service Code
|
NDC 65862022660
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Cash Price |
$25.33
|
| Rate for Payer: Health Management Network Commercial |
$33.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.07
|
| Rate for Payer: MDX Hawaii PPO |
$37.80
|
|
|
clarithromycin 500 mg tablet [HHSC]
|
Facility
|
OP
|
$39.56
|
|
|
Service Code
|
NDC 68084065125
|
| Hospital Charge Code |
2500183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.78 |
| Max. Negotiated Rate |
$38.37 |
| Rate for Payer: AlohaCare Medicaid |
$19.78
|
| Rate for Payer: AlohaCare Medicare |
$19.78
|
| Rate for Payer: Cash Price |
$25.71
|
| Rate for Payer: Devoted Health Medicare |
$21.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.58
|
| Rate for Payer: Health Management Network Commercial |
$33.63
|
| Rate for Payer: Humana Medicare |
$19.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.78
|
| Rate for Payer: MDX Hawaii PPO |
$38.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.78
|
| Rate for Payer: University Health Alliance Commercial |
$28.84
|
|
|
CLAVICLE FRACTURE PLATE, 7 HOLE, STRAIGHT STERILE
|
Facility
|
OP
|
$2,679.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12974365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,339.50 |
| Max. Negotiated Rate |
$2,598.63 |
| Rate for Payer: AlohaCare Medicaid |
$1,339.50
|
| Rate for Payer: AlohaCare Medicare |
$1,339.50
|
| Rate for Payer: Cash Price |
$1,741.35
|
| Rate for Payer: Devoted Health Medicare |
$1,473.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,339.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,875.30
|
| Rate for Payer: Health Management Network Commercial |
$2,277.15
|
| Rate for Payer: Humana Medicare |
$1,339.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,411.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,366.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,339.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,598.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,339.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,339.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,339.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,500.24
|
|
|
CLAVICLE FRACTURE PLATE, 7 HOLE, STRAIGHT STERILE
|
Facility
|
IP
|
$2,679.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12974365
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.24 |
| Max. Negotiated Rate |
$2,598.63 |
| Rate for Payer: Cash Price |
$1,741.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,875.30
|
| Rate for Payer: Health Management Network Commercial |
$2,277.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,411.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,598.63
|
| Rate for Payer: University Health Alliance Commercial |
$1,500.24
|
|
|
CLEARANCE OF AIRWAYS CHARGE
|
Facility
|
OP
|
$428.00
|
|
|
Service Code
|
HCPCS 31720
|
| Hospital Charge Code |
8243387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.17 |
| Max. Negotiated Rate |
$2,389.00 |
| Rate for Payer: AlohaCare Medicaid |
$214.00
|
| Rate for Payer: AlohaCare Medicare |
$214.00
|
| Rate for Payer: Cash Price |
$278.20
|
| Rate for Payer: Cash Price |
$278.20
|
| Rate for Payer: Cash Price |
$278.20
|
| Rate for Payer: Devoted Health Medicare |
$235.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,389.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$214.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$407.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$406.60
|
| Rate for Payer: Health Management Network Commercial |
$363.80
|
| Rate for Payer: Humana Medicare |
$214.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$385.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$218.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$214.00
|
| Rate for Payer: MDX Hawaii PPO |
$415.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$214.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$214.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$214.00
|
| Rate for Payer: University Health Alliance Commercial |
$311.97
|
|
|
CLEARANCE OF AIRWAYS CHARGE
|
Facility
|
IP
|
$428.00
|
|
|
Service Code
|
HCPCS 31720
|
| Hospital Charge Code |
8243387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$363.80 |
| Max. Negotiated Rate |
$415.16 |
| Rate for Payer: Cash Price |
$278.20
|
| Rate for Payer: Health Management Network Commercial |
$363.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$385.20
|
| Rate for Payer: MDX Hawaii PPO |
$415.16
|
|
|
clevidipine 50 mg/100 mL RTU vial [HHSC]
|
Facility
|
OP
|
$684.06
|
|
|
Service Code
|
NDC 10122061110
|
| Hospital Charge Code |
2501196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.03 |
| Max. Negotiated Rate |
$663.54 |
| Rate for Payer: AlohaCare Medicaid |
$342.03
|
| Rate for Payer: AlohaCare Medicare |
$342.03
|
| Rate for Payer: Cash Price |
$444.64
|
| Rate for Payer: Devoted Health Medicare |
$376.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$342.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$649.86
|
| Rate for Payer: Health Management Network Commercial |
$581.45
|
| Rate for Payer: Humana Medicare |
$342.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$348.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.03
|
| Rate for Payer: MDX Hawaii PPO |
$663.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$342.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$342.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$410.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$342.03
|
| Rate for Payer: University Health Alliance Commercial |
$498.61
|
|
|
clevidipine 50 mg/100 mL RTU vial [HHSC]
|
Facility
|
IP
|
$684.06
|
|
|
Service Code
|
NDC 10122061110
|
| Hospital Charge Code |
2501196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.45 |
| Max. Negotiated Rate |
$663.54 |
| Rate for Payer: Cash Price |
$444.64
|
| Rate for Payer: Health Management Network Commercial |
$581.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$615.65
|
| Rate for Payer: MDX Hawaii PPO |
$663.54
|
|
|
CLH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862888
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
CLH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862888
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
clindamycin 150 mg capsule [HHSC]
|
Facility
|
IP
|
$3.49
|
|
|
Service Code
|
NDC 68084024301
|
| Hospital Charge Code |
2500184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$3.39 |
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Health Management Network Commercial |
$2.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.14
|
| Rate for Payer: MDX Hawaii PPO |
$3.39
|
|
|
clindamycin 150 mg capsule [HHSC]
|
Facility
|
OP
|
$4.06
|
|
|
Service Code
|
NDC 00904595961
|
| Hospital Charge Code |
2500184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: AlohaCare Medicaid |
$2.03
|
| Rate for Payer: AlohaCare Medicare |
$2.03
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Devoted Health Medicare |
$2.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.86
|
| Rate for Payer: Health Management Network Commercial |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.03
|
| Rate for Payer: MDX Hawaii PPO |
$3.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.03
|
| Rate for Payer: University Health Alliance Commercial |
$2.96
|
|
