|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904530660
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904530660
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 50 mg/ml vial [HHSC]
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2500262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$3.61 |
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cash Price |
$11.93
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Health Management Network Commercial |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$6.04
|
| Rate for Payer: Health Management Network Commercial |
$3.16
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.35
|
| Rate for Payer: MDX Hawaii PPO |
$6.90
|
| Rate for Payer: MDX Hawaii PPO |
$17.80
|
| Rate for Payer: MDX Hawaii PPO |
$3.61
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
|
|
diphenhydrAMINE 50 mg/ml vial [HHSC]
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2500262
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.61 |
| Rate for Payer: AlohaCare Medicaid |
$1.86
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicaid |
$9.18
|
| Rate for Payer: AlohaCare Medicaid |
$3.56
|
| Rate for Payer: AlohaCare Medicare |
$3.56
|
| Rate for Payer: AlohaCare Medicare |
$9.18
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$11.93
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cash Price |
$11.93
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Devoted Health Medicare |
$2.05
|
| Rate for Payer: Devoted Health Medicare |
$3.91
|
| Rate for Payer: Devoted Health Medicare |
$10.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.53
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$3.16
|
| Rate for Payer: Health Management Network Commercial |
$6.04
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Humana Medicare |
$3.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$17.80
|
| Rate for Payer: MDX Hawaii PPO |
$6.90
|
| Rate for Payer: MDX Hawaii PPO |
$3.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$13.38
|
| Rate for Payer: University Health Alliance Commercial |
$2.71
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$5.18
|
|
|
diphenoxylate-atropine 2.5 mg-0.025 mg tab [HHSC]
|
Facility
|
IP
|
$3.89
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2501134
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.50
|
| Rate for Payer: MDX Hawaii PPO |
$3.77
|
|
|
diphenoxylate-atropine 2.5 mg-0.025 mg tab [HHSC]
|
Facility
|
OP
|
$3.89
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2501134
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: AlohaCare Medicaid |
$1.95
|
| Rate for Payer: AlohaCare Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Devoted Health Medicare |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.70
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Humana Medicare |
$1.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.95
|
| Rate for Payer: MDX Hawaii PPO |
$3.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.95
|
| Rate for Payer: University Health Alliance Commercial |
$2.84
|
|
|
diphtheria/tetanus/pertussis, acel (DTaP) 0.5 mL SDV [HHSC]
|
Facility
|
IP
|
$163.29
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
2501179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.80 |
| Max. Negotiated Rate |
$158.39 |
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Health Management Network Commercial |
$138.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.96
|
| Rate for Payer: MDX Hawaii PPO |
$158.39
|
|
|
diphtheria/tetanus/pertussis, acel (DTaP) 0.5 mL SDV [HHSC]
|
Facility
|
OP
|
$163.29
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
2501179
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$158.39 |
| Rate for Payer: AlohaCare Medicaid |
$81.64
|
| Rate for Payer: AlohaCare Medicare |
$81.64
|
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Cash Price |
$106.14
|
| Rate for Payer: Devoted Health Medicare |
$89.81
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$32.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$32.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.13
|
| Rate for Payer: Health Management Network Commercial |
$138.80
|
| Rate for Payer: Humana Medicare |
$81.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.64
|
| Rate for Payer: MDX Hawaii PPO |
$158.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$97.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.64
|
| Rate for Payer: University Health Alliance Commercial |
$119.02
|
|
|
Direct Antiglobulin Test (C3)
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
12499856
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$24.50
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$26.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.39
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$24.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.50
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.88
|
|
|
Direct Antiglobulin Test (C3)
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
12499856
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
Direct Antiglobulin Test (IgG)
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
12499848
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$24.50
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$26.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.39
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$24.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.50
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.88
|
|
|
Direct Antiglobulin Test (IgG)
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
12499848
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
Direct Coombs FSI
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
8128069
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
Direct Coombs FSI
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
8128069
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Devoted Health Medicare |
$69.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.39
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: University Health Alliance Commercial |
$13.88
|
|
|
DIRECT TO OBS CHARGE
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
8281148
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
DIRECT TO OBS CHARGE
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
8281148
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$443.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$443.50
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Devoted Health Medicare |
$487.85
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$443.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$443.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$452.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$443.50
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$443.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$443.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$459.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$443.50
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
Disk Diffusion Susceptibility
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87184
|
| Hospital Charge Code |
12499847
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$7.48 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: AlohaCare Medicaid |
$52.00
|
| Rate for Payer: AlohaCare Medicare |
$52.00
|
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Devoted Health Medicare |
$57.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.48
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Humana Medicare |
$52.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.00
|
| Rate for Payer: University Health Alliance Commercial |
$17.82
|
|
|
Disk Diffusion Susceptibility
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87184
|
| Hospital Charge Code |
12499847
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$34,343.11
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$34,343.11 |
| Max. Negotiated Rate |
$34,343.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34,343.11
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$34,343.11
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$34,343.11 |
| Max. Negotiated Rate |
$34,343.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34,343.11
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$24,833.10
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$24,833.10 |
| Max. Negotiated Rate |
$24,833.10 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,833.10
|
|
