|
DLS5585E- Microscan MIC Susceptibility
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
12600761
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.65 |
| 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 |
$11.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.65
|
| 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 |
$11.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.00
|
| Rate for Payer: University Health Alliance Commercial |
$22.35
|
|
|
DLS5585E- Microscan MIC Susceptibility
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
12600761
|
|
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
|
|
|
DLS5585F- Microscan MIC Susceptibility
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
12600765
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.65 |
| 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 |
$11.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.65
|
| 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 |
$11.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.00
|
| Rate for Payer: University Health Alliance Commercial |
$22.35
|
|
|
DLS5585F- Microscan MIC Susceptibility
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
12600765
|
|
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
|
|
|
DLS SARS CoV-2 (COVID-19) RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8873072
|
|
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
|
|
|
DLS SARS CoV-2 (COVID-19) RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8873072
|
|
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
|
|
|
DMEK TISSUE
|
Facility
|
IP
|
$11,350.00
|
|
|
Service Code
|
HCPCS V2785
|
| Hospital Charge Code |
13156384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,356.00 |
| Max. Negotiated Rate |
$11,009.50 |
| Rate for Payer: Cash Price |
$7,377.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,945.00
|
| Rate for Payer: Health Management Network Commercial |
$9,647.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,215.00
|
| Rate for Payer: MDX Hawaii PPO |
$11,009.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,356.00
|
|
|
DMEK TISSUE
|
Facility
|
OP
|
$11,350.00
|
|
|
Service Code
|
HCPCS V2785
|
| Hospital Charge Code |
13156384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,675.00 |
| Max. Negotiated Rate |
$11,009.50 |
| Rate for Payer: Kaiser Permanente Commercial |
$10,215.00
|
| Rate for Payer: AlohaCare Medicaid |
$5,675.00
|
| Rate for Payer: AlohaCare Medicare |
$5,675.00
|
| Rate for Payer: Cash Price |
$7,377.50
|
| Rate for Payer: Devoted Health Medicare |
$6,242.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,675.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,945.00
|
| Rate for Payer: Health Management Network Commercial |
$9,647.50
|
| Rate for Payer: Humana Medicare |
$5,675.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,788.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,675.00
|
| Rate for Payer: MDX Hawaii PPO |
$11,009.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,675.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,675.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,675.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,356.00
|
|
|
DOBUTamine 250 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$39.79
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$38.60 |
| Rate for Payer: AlohaCare Medicaid |
$19.89
|
| Rate for Payer: AlohaCare Medicaid |
$27.11
|
| Rate for Payer: AlohaCare Medicaid |
$21.05
|
| Rate for Payer: AlohaCare Medicare |
$21.05
|
| Rate for Payer: AlohaCare Medicare |
$19.89
|
| Rate for Payer: AlohaCare Medicare |
$27.11
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Devoted Health Medicare |
$21.88
|
| Rate for Payer: Devoted Health Medicare |
$29.82
|
| Rate for Payer: Devoted Health Medicare |
$23.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.51
|
| Rate for Payer: Health Management Network Commercial |
$46.09
|
| Rate for Payer: Health Management Network Commercial |
$33.82
|
| Rate for Payer: Health Management Network Commercial |
$35.79
|
| Rate for Payer: Humana Medicare |
$19.89
|
| Rate for Payer: Humana Medicare |
$21.05
|
| Rate for Payer: Humana Medicare |
$27.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.11
|
| Rate for Payer: MDX Hawaii PPO |
$52.59
|
| Rate for Payer: MDX Hawaii PPO |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$38.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.11
|
| Rate for Payer: University Health Alliance Commercial |
$29.00
|
| Rate for Payer: University Health Alliance Commercial |
$30.69
|
| Rate for Payer: University Health Alliance Commercial |
$39.52
|
|
|
DOBUTamine 250 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$54.22
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.09 |
| Max. Negotiated Rate |
$52.59 |
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Health Management Network Commercial |
$33.82
|
| Rate for Payer: Health Management Network Commercial |
$46.09
|
| Rate for Payer: Health Management Network Commercial |
$35.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.81
|
| Rate for Payer: MDX Hawaii PPO |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$38.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.59
|
|
|
DOBUTamine-D5W 250mg/250ml premix [HHSC]
|
Facility
|
IP
|
$114.70
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$111.26 |
| Rate for Payer: Cash Price |
$74.56
|
| Rate for Payer: Cash Price |
$48.20
|
| Rate for Payer: Health Management Network Commercial |
$97.50
|
| Rate for Payer: Health Management Network Commercial |
$63.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.74
|
| Rate for Payer: MDX Hawaii PPO |
$71.94
|
| Rate for Payer: MDX Hawaii PPO |
$111.26
|
|
|
DOBUTamine-D5W 250mg/250ml premix [HHSC]
|
Facility
|
OP
|
$114.70
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$111.26 |
| Rate for Payer: AlohaCare Medicaid |
$57.35
|
| Rate for Payer: AlohaCare Medicaid |
$37.08
|
| Rate for Payer: AlohaCare Medicare |
$37.08
|
| Rate for Payer: AlohaCare Medicare |
$57.35
|
| Rate for Payer: Cash Price |
$48.20
|
| Rate for Payer: Cash Price |
$74.56
|
| Rate for Payer: Cash Price |
$74.56
|
| Rate for Payer: Cash Price |
$48.20
|
| Rate for Payer: Devoted Health Medicare |
$63.09
|
| Rate for Payer: Devoted Health Medicare |
$40.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.45
|
| Rate for Payer: Health Management Network Commercial |
$63.04
|
| Rate for Payer: Health Management Network Commercial |
$97.50
|
| Rate for Payer: Humana Medicare |
$57.35
|
| Rate for Payer: Humana Medicare |
$37.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.08
|
| Rate for Payer: MDX Hawaii PPO |
$111.26
|
| Rate for Payer: MDX Hawaii PPO |
$71.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.08
|
| Rate for Payer: University Health Alliance Commercial |
$83.60
|
| Rate for Payer: University Health Alliance Commercial |
$54.06
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
IP
|
$12.34
|
|
|
Service Code
|
NDC 00121187000
|
| Hospital Charge Code |
2500268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$11.97 |
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Health Management Network Commercial |
$10.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.11
|
| Rate for Payer: MDX Hawaii PPO |
$11.97
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
OP
|
$3.89
|
|
|
Service Code
|
NDC 00121054410
|
| Hospital Charge Code |
2500268
|
|
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
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
OP
|
$12.34
|
|
|
Service Code
|
NDC 00121187000
|
| Hospital Charge Code |
2500268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$11.97 |
| Rate for Payer: AlohaCare Medicaid |
$6.17
|
| Rate for Payer: AlohaCare Medicare |
$6.17
|
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Devoted Health Medicare |
$6.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.72
|
| Rate for Payer: Health Management Network Commercial |
$10.49
|
| Rate for Payer: Humana Medicare |
$6.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.17
|
| Rate for Payer: MDX Hawaii PPO |
$11.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.17
|
| Rate for Payer: University Health Alliance Commercial |
$8.99
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
OP
|
$7.60
|
|
|
Service Code
|
NDC 00904727972
|
| Hospital Charge Code |
2500268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$7.37 |
| Rate for Payer: AlohaCare Medicaid |
$3.80
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Devoted Health Medicare |
$4.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.22
|
| Rate for Payer: Health Management Network Commercial |
$6.46
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$5.54
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
IP
|
$7.60
|
|
|
Service Code
|
NDC 00904727972
|
| Hospital Charge Code |
2500268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$7.37 |
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Health Management Network Commercial |
$6.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$7.37
|
|
|
docusate sodium 100 mg/10 mL cup [HHSC]
|
Facility
|
IP
|
$3.89
|
|
|
Service Code
|
NDC 00121054410
|
| Hospital Charge Code |
2500268
|
|
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
|
|
|
docusate sodium 100 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
| Hospital Charge Code |
2500267
|
|
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
|
|
|
docusate sodium 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
| Hospital Charge Code |
2500267
|
|
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
|
|
|
DOH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862906
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
DOH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862906
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
DOH Testing FSI
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
8117902
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$45.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Devoted Health Medicare |
$49.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.63
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$45.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.00
|
| Rate for Payer: University Health Alliance Commercial |
$17.13
|
|
|
DOH Testing FSI
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
8117902
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
donepezil 5 mg tablet [HHSC]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
2500271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: AlohaCare Medicaid |
$2.16
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.10
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: University Health Alliance Commercial |
$3.15
|
|
