|
EPINEPHrine 1 mg/mL PF soln [HHSC]
|
Facility
|
IP
|
$91.30
|
|
|
Service Code
|
HCPCS J0166
|
| Hospital Charge Code |
2500296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.61 |
| Max. Negotiated Rate |
$88.56 |
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
|
|
EPINEPHrine 4 mg/250 mL-NS premix [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
HCPCS J0169
|
| Hospital Charge Code |
2501189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
EPINEPHrine 4 mg/250 mL-NS premix [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
HCPCS J0169
|
| Hospital Charge Code |
2501189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$280.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
|
EPISTAXIS WITH MCC
|
Facility
|
IP
|
$11,192.74
|
|
|
Service Code
|
MSDRG 150
|
| Min. Negotiated Rate |
$11,192.74 |
| Max. Negotiated Rate |
$11,192.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11,192.74
|
|
|
EPISTAXIS WITHOUT MCC
|
Facility
|
IP
|
$11,192.74
|
|
|
Service Code
|
MSDRG 151
|
| Min. Negotiated Rate |
$11,192.74 |
| Max. Negotiated Rate |
$11,192.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11,192.74
|
|
|
epoetin alfa 10,000 units/1mL (PF) [HHSC]
|
Facility
|
IP
|
$887.11
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
2500301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$754.04 |
| Max. Negotiated Rate |
$860.50 |
| Rate for Payer: Cash Price |
$576.62
|
| Rate for Payer: Health Management Network Commercial |
$754.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.40
|
| Rate for Payer: MDX Hawaii PPO |
$860.50
|
|
|
epoetin alfa 10,000 units/1mL (PF) [HHSC]
|
Facility
|
OP
|
$887.11
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
2500301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.68 |
| Max. Negotiated Rate |
$860.50 |
| Rate for Payer: AlohaCare Medicaid |
$443.56
|
| Rate for Payer: AlohaCare Medicare |
$443.56
|
| Rate for Payer: Cash Price |
$576.62
|
| Rate for Payer: Cash Price |
$576.62
|
| Rate for Payer: Devoted Health Medicare |
$487.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$443.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.75
|
| Rate for Payer: Health Management Network Commercial |
$754.04
|
| Rate for Payer: Humana Medicare |
$443.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$452.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$443.56
|
| Rate for Payer: MDX Hawaii PPO |
$860.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$443.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$443.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$532.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$443.56
|
| Rate for Payer: University Health Alliance Commercial |
$646.61
|
|
|
eptifibatide 20mg/10 mL vial [HHSC]
|
Facility
|
OP
|
$617.75
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
2500303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$599.22 |
| Rate for Payer: AlohaCare Medicaid |
$308.88
|
| Rate for Payer: AlohaCare Medicaid |
$317.20
|
| Rate for Payer: AlohaCare Medicaid |
$84.31
|
| Rate for Payer: AlohaCare Medicaid |
$232.60
|
| Rate for Payer: AlohaCare Medicaid |
$356.12
|
| Rate for Payer: AlohaCare Medicare |
$356.12
|
| Rate for Payer: AlohaCare Medicare |
$232.60
|
| Rate for Payer: AlohaCare Medicare |
$84.31
|
| Rate for Payer: AlohaCare Medicare |
$308.88
|
| Rate for Payer: AlohaCare Medicare |
$317.20
|
| Rate for Payer: Cash Price |
$401.54
|
| Rate for Payer: Cash Price |
$302.39
|
| Rate for Payer: Cash Price |
$412.36
|
| Rate for Payer: Cash Price |
$401.54
|
| Rate for Payer: Cash Price |
$462.96
|
| Rate for Payer: Cash Price |
$302.39
|
| Rate for Payer: Cash Price |
$462.96
|
| Rate for Payer: Cash Price |
$412.36
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Devoted Health Medicare |
$348.92
|
| Rate for Payer: Devoted Health Medicare |
$92.75
|
| Rate for Payer: Devoted Health Medicare |
$339.76
|
| Rate for Payer: Devoted Health Medicare |
$255.87
|
| Rate for Payer: Devoted Health Medicare |
$391.74
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$308.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$317.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$586.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$676.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$441.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$602.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$160.20
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Health Management Network Commercial |
$605.41
|
| Rate for Payer: Health Management Network Commercial |
$525.09
|
| Rate for Payer: Health Management Network Commercial |
$539.24
|
| Rate for Payer: Health Management Network Commercial |
$395.43
|
| Rate for Payer: Humana Medicare |
$308.88
|
| Rate for Payer: Humana Medicare |
$84.31
|
| Rate for Payer: Humana Medicare |
$232.60
|
| Rate for Payer: Humana Medicare |
$317.20
|
| Rate for Payer: Humana Medicare |
$356.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$570.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$641.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$555.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$418.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$323.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$237.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$317.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$308.88
|
| Rate for Payer: MDX Hawaii PPO |
$451.25
|
| Rate for Payer: MDX Hawaii PPO |
$599.22
|
| Rate for Payer: MDX Hawaii PPO |
$615.37
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
| Rate for Payer: MDX Hawaii PPO |
$690.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$317.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$308.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$308.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$317.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$427.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$380.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$279.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$370.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$317.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$308.88
|
| Rate for Payer: University Health Alliance Commercial |
$122.91
|
| Rate for Payer: University Health Alliance Commercial |
$450.28
|
| Rate for Payer: University Health Alliance Commercial |
$339.09
|
| Rate for Payer: University Health Alliance Commercial |
$462.41
|
| Rate for Payer: University Health Alliance Commercial |
$519.16
|
|
|
eptifibatide 20mg/10 mL vial [HHSC]
|
Facility
|
IP
|
$168.63
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
2500303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.34 |
| Max. Negotiated Rate |
$163.57 |
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$401.54
|
| Rate for Payer: Cash Price |
$462.96
|
| Rate for Payer: Cash Price |
$412.36
|
| Rate for Payer: Cash Price |
$302.39
|
| Rate for Payer: Health Management Network Commercial |
$605.41
|
| Rate for Payer: Health Management Network Commercial |
$395.43
|
| Rate for Payer: Health Management Network Commercial |
$525.09
|
| Rate for Payer: Health Management Network Commercial |
$539.24
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$418.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$570.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$641.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$555.98
|
| Rate for Payer: MDX Hawaii PPO |
$690.88
|
| Rate for Payer: MDX Hawaii PPO |
$599.22
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
| Rate for Payer: MDX Hawaii PPO |
$615.37
|
| Rate for Payer: MDX Hawaii PPO |
$451.25
|
|
|
eptifibatide 75 mg/100mL RTU vial [HHSC]
|
Facility
|
IP
|
$1,221.71
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
2500302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,038.45 |
| Max. Negotiated Rate |
$1,185.06 |
| Rate for Payer: Cash Price |
$794.11
|
| Rate for Payer: Cash Price |
$922.75
|
| Rate for Payer: Cash Price |
$955.51
|
| Rate for Payer: Cash Price |
$997.36
|
| Rate for Payer: Cash Price |
$1,115.04
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$564.85
|
| Rate for Payer: Health Management Network Commercial |
$418.88
|
| Rate for Payer: Health Management Network Commercial |
$1,038.45
|
| Rate for Payer: Health Management Network Commercial |
$738.65
|
| Rate for Payer: Health Management Network Commercial |
$1,304.24
|
| Rate for Payer: Health Management Network Commercial |
$1,458.13
|
| Rate for Payer: Health Management Network Commercial |
$1,249.52
|
| Rate for Payer: Health Management Network Commercial |
$1,206.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,380.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$443.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$782.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,277.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,099.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,543.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,663.99
|
| Rate for Payer: MDX Hawaii PPO |
$842.93
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.92
|
| Rate for Payer: MDX Hawaii PPO |
$1,488.37
|
| Rate for Payer: MDX Hawaii PPO |
$1,377.02
|
| Rate for Payer: MDX Hawaii PPO |
$478.02
|
| Rate for Payer: MDX Hawaii PPO |
$1,185.06
|
|
|
eptifibatide 75 mg/100mL RTU vial [HHSC]
|
Facility
|
OP
|
$492.80
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
2500302
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$478.02 |
| Rate for Payer: AlohaCare Medicaid |
$246.40
|
| Rate for Payer: AlohaCare Medicaid |
$434.50
|
| Rate for Payer: AlohaCare Medicaid |
$610.86
|
| Rate for Payer: AlohaCare Medicaid |
$709.80
|
| Rate for Payer: AlohaCare Medicaid |
$767.20
|
| Rate for Payer: AlohaCare Medicaid |
$857.73
|
| Rate for Payer: AlohaCare Medicaid |
$735.01
|
| Rate for Payer: AlohaCare Medicare |
$735.01
|
| Rate for Payer: AlohaCare Medicare |
$246.40
|
| Rate for Payer: AlohaCare Medicare |
$857.73
|
| Rate for Payer: AlohaCare Medicare |
$709.80
|
| Rate for Payer: AlohaCare Medicare |
$434.50
|
| Rate for Payer: AlohaCare Medicare |
$610.86
|
| Rate for Payer: AlohaCare Medicare |
$767.20
|
| Rate for Payer: Cash Price |
$922.75
|
| Rate for Payer: Cash Price |
$997.36
|
| Rate for Payer: Cash Price |
$794.11
|
| Rate for Payer: Cash Price |
$794.11
|
| Rate for Payer: Cash Price |
$922.75
|
| Rate for Payer: Cash Price |
$564.85
|
| Rate for Payer: Cash Price |
$564.85
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$320.32
|
| Rate for Payer: Cash Price |
$1,115.04
|
| Rate for Payer: Cash Price |
$955.51
|
| Rate for Payer: Cash Price |
$955.51
|
| Rate for Payer: Cash Price |
$1,115.04
|
| Rate for Payer: Cash Price |
$997.36
|
| Rate for Payer: Devoted Health Medicare |
$271.04
|
| Rate for Payer: Devoted Health Medicare |
$943.50
|
| Rate for Payer: Devoted Health Medicare |
$843.92
|
| Rate for Payer: Devoted Health Medicare |
$808.51
|
| Rate for Payer: Devoted Health Medicare |
$477.95
|
| Rate for Payer: Devoted Health Medicare |
$671.94
|
| Rate for Payer: Devoted Health Medicare |
$780.79
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$709.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$857.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$767.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$735.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$434.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$610.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,629.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$825.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,457.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,348.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$468.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,160.62
|
| Rate for Payer: Health Management Network Commercial |
$1,206.67
|
| Rate for Payer: Health Management Network Commercial |
$1,038.45
|
| Rate for Payer: Health Management Network Commercial |
$1,249.52
|
| Rate for Payer: Health Management Network Commercial |
$1,304.24
|
| Rate for Payer: Health Management Network Commercial |
$1,458.13
|
| Rate for Payer: Health Management Network Commercial |
$418.88
|
| Rate for Payer: Health Management Network Commercial |
$738.65
|
| Rate for Payer: Humana Medicare |
$246.40
|
| Rate for Payer: Humana Medicare |
$767.20
|
| Rate for Payer: Humana Medicare |
$434.50
|
| Rate for Payer: Humana Medicare |
$735.01
|
| Rate for Payer: Humana Medicare |
$610.86
|
| Rate for Payer: Humana Medicare |
$709.80
|
| Rate for Payer: Humana Medicare |
$857.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$443.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,380.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$782.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,543.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,099.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,277.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$874.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$782.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$623.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$443.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$724.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$251.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$767.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$434.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$709.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$735.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$857.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$610.86
|
| Rate for Payer: MDX Hawaii PPO |
$1,663.99
|
| Rate for Payer: MDX Hawaii PPO |
$1,488.37
|
| Rate for Payer: MDX Hawaii PPO |
$478.02
|
| Rate for Payer: MDX Hawaii PPO |
$1,377.02
|
| Rate for Payer: MDX Hawaii PPO |
$1,185.06
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.92
|
| Rate for Payer: MDX Hawaii PPO |
$842.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$857.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$767.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$735.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$610.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$709.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$246.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$434.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$709.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$246.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$857.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$767.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$434.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$735.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$610.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$295.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$882.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$733.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$851.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$920.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,029.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$857.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$434.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$610.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$709.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$767.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$735.01
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.50
|
| Rate for Payer: University Health Alliance Commercial |
$633.41
|
| Rate for Payer: University Health Alliance Commercial |
$1,034.75
|
| Rate for Payer: University Health Alliance Commercial |
$1,250.39
|
| Rate for Payer: University Health Alliance Commercial |
$890.50
|
| Rate for Payer: University Health Alliance Commercial |
$359.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,118.42
|
|
|
ER 2ND PROCEDURE TechFee
|
Facility
|
IP
|
$560.00
|
|
| Hospital Charge Code |
8265129
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$476.00 |
| Max. Negotiated Rate |
$543.20 |
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Health Management Network Commercial |
$476.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.00
|
| Rate for Payer: MDX Hawaii PPO |
$543.20
|
|
|
ER 2ND PROCEDURE TechFee
|
Facility
|
OP
|
$560.00
|
|
| Hospital Charge Code |
8265129
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Ohana Health Plan Medicaid |
$280.00
|
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$280.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Devoted Health Medicare |
$308.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$280.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$532.00
|
| Rate for Payer: Health Management Network Commercial |
$476.00
|
| Rate for Payer: Humana Medicare |
$280.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$504.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$280.00
|
| Rate for Payer: MDX Hawaii PPO |
$543.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$280.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$280.00
|
| Rate for Payer: University Health Alliance Commercial |
$408.18
|
|
|
ER FACILITY PROCEDURE, LEVEL 2
|
Facility
|
IP
|
$925.00
|
|
| Hospital Charge Code |
8301084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$786.25 |
| Max. Negotiated Rate |
$897.25 |
| Rate for Payer: Cash Price |
$601.25
|
| Rate for Payer: Health Management Network Commercial |
$786.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$832.50
|
| Rate for Payer: MDX Hawaii PPO |
$897.25
|
|
|
ER FACILITY PROCEDURE, LEVEL 2
|
Facility
|
OP
|
$925.00
|
|
| Hospital Charge Code |
8301084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$462.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$462.50
|
| Rate for Payer: Cash Price |
$601.25
|
| Rate for Payer: Cash Price |
$601.25
|
| Rate for Payer: Cash Price |
$601.25
|
| Rate for Payer: Devoted Health Medicare |
$508.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$462.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$878.75
|
| Rate for Payer: Health Management Network Commercial |
$786.25
|
| Rate for Payer: Humana Medicare |
$462.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$832.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$462.50
|
| Rate for Payer: MDX Hawaii PPO |
$897.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$462.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$462.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$462.50
|
| Rate for Payer: University Health Alliance Commercial |
$674.23
|
|
|
ER FACILITY PROCEDURE, LEVEL 3
|
Facility
|
IP
|
$1,880.00
|
|
| Hospital Charge Code |
8301085
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,598.00 |
| Max. Negotiated Rate |
$1,823.60 |
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Health Management Network Commercial |
$1,598.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,692.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,823.60
|
|
|
ER FACILITY PROCEDURE, LEVEL 3
|
Facility
|
OP
|
$1,880.00
|
|
| Hospital Charge Code |
8301085
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$1,823.60 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$940.00
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Devoted Health Medicare |
$1,034.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$940.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,786.00
|
| Rate for Payer: Health Management Network Commercial |
$1,598.00
|
| Rate for Payer: Humana Medicare |
$940.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,692.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$940.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,823.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$940.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$940.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$940.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,370.33
|
|
|
ER FACILITY PROCEDURE, LEVEL 4
|
Facility
|
OP
|
$2,850.00
|
|
| Hospital Charge Code |
8301086
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$1,425.00
|
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Devoted Health Medicare |
$1,567.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,425.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,707.50
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Humana Medicare |
$1,425.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,425.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,425.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,425.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,425.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,077.36
|
|
|
ER FACILITY PROCEDURE, LEVEL 4
|
Facility
|
IP
|
$2,850.00
|
|
| Hospital Charge Code |
8301086
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,422.50 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
|
|
ER FACILITY PROCEDURE, LEVEL 5
|
Facility
|
OP
|
$6,850.00
|
|
| Hospital Charge Code |
8301087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$6,644.50 |
| Rate for Payer: Ohana Health Plan Medicaid |
$3,425.00
|
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$3,425.00
|
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Devoted Health Medicare |
$3,767.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$588.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,425.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,507.50
|
| Rate for Payer: Health Management Network Commercial |
$5,822.50
|
| Rate for Payer: Humana Medicare |
$3,425.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,165.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,425.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,644.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,425.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,425.00
|
| Rate for Payer: University Health Alliance Commercial |
$4,992.97
|
|
|
ER FACILITY PROCEDURE, LEVEL 5
|
Facility
|
IP
|
$6,850.00
|
|
| Hospital Charge Code |
8301087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,822.50 |
| Max. Negotiated Rate |
$6,644.50 |
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Health Management Network Commercial |
$5,822.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,165.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,644.50
|
|
|
erythromycin 0.5% ophth oint 1gm [HHSC]
|
Facility
|
IP
|
$70.02
|
|
|
Service Code
|
NDC 24208091019
|
| Hospital Charge Code |
2500308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$67.92 |
| Rate for Payer: Cash Price |
$45.51
|
| Rate for Payer: Health Management Network Commercial |
$59.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.02
|
| Rate for Payer: MDX Hawaii PPO |
$67.92
|
|
|
erythromycin 0.5% ophth oint 1gm [HHSC]
|
Facility
|
IP
|
$101.90
|
|
|
Service Code
|
NDC 72485067031
|
| Hospital Charge Code |
2500308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.61 |
| Max. Negotiated Rate |
$98.84 |
| Rate for Payer: Cash Price |
$66.24
|
| Rate for Payer: Health Management Network Commercial |
$86.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.71
|
| Rate for Payer: MDX Hawaii PPO |
$98.84
|
|
|
erythromycin 0.5% ophth oint 1gm [HHSC]
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
NDC 00574402450
|
| Hospital Charge Code |
2500308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.02 |
| Max. Negotiated Rate |
$50.47 |
| Rate for Payer: AlohaCare Medicaid |
$26.02
|
| Rate for Payer: AlohaCare Medicare |
$26.02
|
| Rate for Payer: Cash Price |
$33.82
|
| Rate for Payer: Devoted Health Medicare |
$28.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.43
|
| Rate for Payer: Health Management Network Commercial |
$44.23
|
| Rate for Payer: Humana Medicare |
$26.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.02
|
| Rate for Payer: MDX Hawaii PPO |
$50.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.02
|
| Rate for Payer: University Health Alliance Commercial |
$37.92
|
|
|
erythromycin 0.5% ophth oint 1gm [HHSC]
|
Facility
|
OP
|
$101.90
|
|
|
Service Code
|
NDC 72485067031
|
| Hospital Charge Code |
2500308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.95 |
| Max. Negotiated Rate |
$98.84 |
| Rate for Payer: AlohaCare Medicaid |
$50.95
|
| Rate for Payer: AlohaCare Medicare |
$50.95
|
| Rate for Payer: Cash Price |
$66.24
|
| Rate for Payer: Devoted Health Medicare |
$56.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.81
|
| Rate for Payer: Health Management Network Commercial |
$86.61
|
| Rate for Payer: Humana Medicare |
$50.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.95
|
| Rate for Payer: MDX Hawaii PPO |
$98.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.95
|
| Rate for Payer: University Health Alliance Commercial |
$74.27
|
|
