|
iohexol 300 mg/mL (PF) 100 mL [HHSC]
|
Facility
|
OP
|
$463.12
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2501018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$449.23 |
| Rate for Payer: AlohaCare Medicaid |
$231.56
|
| Rate for Payer: AlohaCare Medicaid |
$234.85
|
| Rate for Payer: AlohaCare Medicare |
$234.85
|
| Rate for Payer: AlohaCare Medicare |
$231.56
|
| Rate for Payer: Cash Price |
$305.30
|
| Rate for Payer: Cash Price |
$301.03
|
| Rate for Payer: Cash Price |
$301.03
|
| Rate for Payer: Cash Price |
$305.30
|
| Rate for Payer: Devoted Health Medicare |
$254.72
|
| Rate for Payer: Devoted Health Medicare |
$258.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$234.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$231.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$439.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$446.21
|
| Rate for Payer: Health Management Network Commercial |
$399.25
|
| Rate for Payer: Health Management Network Commercial |
$393.65
|
| Rate for Payer: Humana Medicare |
$231.56
|
| Rate for Payer: Humana Medicare |
$234.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$416.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$239.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$231.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$234.85
|
| Rate for Payer: MDX Hawaii PPO |
$449.23
|
| Rate for Payer: MDX Hawaii PPO |
$455.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$234.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$231.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$231.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$234.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$281.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$277.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$231.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$234.85
|
| Rate for Payer: University Health Alliance Commercial |
$337.57
|
| Rate for Payer: University Health Alliance Commercial |
$342.36
|
|
|
iohexol 300 mg/mL (PF) 10 mL [HHSC]
|
Facility
|
IP
|
$296.08
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2500888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.67 |
| Max. Negotiated Rate |
$287.20 |
| Rate for Payer: Cash Price |
$192.45
|
| Rate for Payer: Health Management Network Commercial |
$251.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$266.47
|
| Rate for Payer: MDX Hawaii PPO |
$287.20
|
|
|
iohexol 300 mg/mL (PF) 10 mL [HHSC]
|
Facility
|
OP
|
$296.08
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2500888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$287.20 |
| Rate for Payer: AlohaCare Medicaid |
$148.04
|
| Rate for Payer: AlohaCare Medicare |
$148.04
|
| Rate for Payer: Cash Price |
$192.45
|
| Rate for Payer: Cash Price |
$192.45
|
| Rate for Payer: Devoted Health Medicare |
$162.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.28
|
| Rate for Payer: Health Management Network Commercial |
$251.67
|
| Rate for Payer: Humana Medicare |
$148.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$266.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$148.04
|
| Rate for Payer: MDX Hawaii PPO |
$287.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$148.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$177.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.04
|
| Rate for Payer: University Health Alliance Commercial |
$215.81
|
|
|
iohexol 350 mg/mL (PF) 100 mL [HHSC]
|
Facility
|
OP
|
$487.74
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3508007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$473.11 |
| Rate for Payer: AlohaCare Medicaid |
$243.87
|
| Rate for Payer: AlohaCare Medicaid |
$247.51
|
| Rate for Payer: AlohaCare Medicare |
$247.51
|
| Rate for Payer: AlohaCare Medicare |
$243.87
|
| Rate for Payer: Cash Price |
$321.77
|
| Rate for Payer: Cash Price |
$317.03
|
| Rate for Payer: Cash Price |
$317.03
|
| Rate for Payer: Cash Price |
$321.77
|
| Rate for Payer: Devoted Health Medicare |
$268.26
|
| Rate for Payer: Devoted Health Medicare |
$272.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$247.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$243.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$470.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$463.35
|
| Rate for Payer: Health Management Network Commercial |
$414.58
|
| Rate for Payer: Health Management Network Commercial |
$420.78
|
| Rate for Payer: Humana Medicare |
$247.51
|
| Rate for Payer: Humana Medicare |
$243.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$438.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$252.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$248.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$247.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$243.87
|
| Rate for Payer: MDX Hawaii PPO |
$473.11
|
| Rate for Payer: MDX Hawaii PPO |
$480.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$243.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$247.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$243.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$247.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$292.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$297.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$247.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$243.87
|
| Rate for Payer: University Health Alliance Commercial |
$355.51
|
| Rate for Payer: University Health Alliance Commercial |
$360.83
|
|
|
iohexol 350 mg/mL (PF) 100 mL [HHSC]
|
Facility
|
IP
|
$487.74
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3508007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$414.58 |
| Max. Negotiated Rate |
$473.11 |
| Rate for Payer: Cash Price |
$317.03
|
| Rate for Payer: Cash Price |
$321.77
|
| Rate for Payer: Health Management Network Commercial |
$420.78
|
| Rate for Payer: Health Management Network Commercial |
$414.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$438.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.53
|
| Rate for Payer: MDX Hawaii PPO |
$480.18
|
| Rate for Payer: MDX Hawaii PPO |
$473.11
|
|
|
iohexol 9 mg/mL 500 mL oral solution [HHSC]
|
Facility
|
OP
|
$68.81
|
|
|
Service Code
|
NDC 00407141509
|
| Hospital Charge Code |
2501117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.41 |
| Max. Negotiated Rate |
$66.75 |
| Rate for Payer: AlohaCare Medicaid |
$34.41
|
| Rate for Payer: AlohaCare Medicare |
$34.41
|
| Rate for Payer: Cash Price |
$44.73
|
| Rate for Payer: Devoted Health Medicare |
$37.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.37
|
| Rate for Payer: Health Management Network Commercial |
$58.49
|
| Rate for Payer: Humana Medicare |
$34.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.41
|
| Rate for Payer: MDX Hawaii PPO |
$66.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.41
|
| Rate for Payer: University Health Alliance Commercial |
$50.16
|
|
|
iohexol 9 mg/mL 500 mL oral solution [HHSC]
|
Facility
|
IP
|
$68.81
|
|
|
Service Code
|
NDC 00407141509
|
| Hospital Charge Code |
2501117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.49 |
| Max. Negotiated Rate |
$66.75 |
| Rate for Payer: Cash Price |
$44.73
|
| Rate for Payer: Health Management Network Commercial |
$58.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.93
|
| Rate for Payer: MDX Hawaii PPO |
$66.75
|
|
|
Ionized Calcium FSI
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
8117974
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$78.50
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Devoted Health Medicare |
$86.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.68
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$78.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.50
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.32
|
|
|
Ionized Calcium FSI
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
8117974
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$133.45 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
|
|
Iontophoresis Charges
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 97033 GP,CQ
|
| Hospital Charge Code |
8123824
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicare |
$70.50
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Devoted Health Medicare |
$77.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.95
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$70.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.50
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.50
|
| Rate for Payer: University Health Alliance Commercial |
$102.77
|
|
|
Iontophoresis Charges
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS 97033 GP,CQ
|
| Hospital Charge Code |
8123824
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$119.85 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
|
|
Iontophoresis Charges
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS 97033 GP,CQ
|
| Hospital Charge Code |
8111685
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$119.85 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
|
|
Iontophoresis Charges
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 97033 GP,CQ
|
| Hospital Charge Code |
8111685
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicare |
$70.50
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Cash Price |
$91.65
|
| Rate for Payer: Devoted Health Medicare |
$77.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.95
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$70.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.50
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.50
|
| Rate for Payer: University Health Alliance Commercial |
$102.77
|
|
|
ipratropium HFA 17 mcg/inh 12.9 g inhaler [HHSC]
|
Facility
|
OP
|
$1,425.92
|
|
|
Service Code
|
NDC 00597008717
|
| Hospital Charge Code |
2500426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$712.96 |
| Max. Negotiated Rate |
$1,383.14 |
| Rate for Payer: AlohaCare Medicaid |
$712.96
|
| Rate for Payer: AlohaCare Medicare |
$712.96
|
| Rate for Payer: Cash Price |
$926.85
|
| Rate for Payer: Devoted Health Medicare |
$784.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$712.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,354.62
|
| Rate for Payer: Health Management Network Commercial |
$1,212.03
|
| Rate for Payer: Humana Medicare |
$712.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,283.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$727.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$712.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,383.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$712.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$712.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$855.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$712.96
|
| Rate for Payer: University Health Alliance Commercial |
$1,039.35
|
|
|
ipratropium HFA 17 mcg/inh 12.9 g inhaler [HHSC]
|
Facility
|
IP
|
$1,425.92
|
|
|
Service Code
|
NDC 00597008717
|
| Hospital Charge Code |
2500426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,212.03 |
| Max. Negotiated Rate |
$1,383.14 |
| Rate for Payer: Cash Price |
$926.85
|
| Rate for Payer: Health Management Network Commercial |
$1,212.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,283.33
|
| Rate for Payer: MDX Hawaii PPO |
$1,383.14
|
|
|
Iron Level FSI
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
8128131
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$57.20
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
Iron Level FSI
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
HCPCS 83540
|
| Hospital Charge Code |
8128131
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: AlohaCare Medicaid |
$44.00
|
| Rate for Payer: AlohaCare Medicare |
$44.00
|
| Rate for Payer: Cash Price |
$57.20
|
| Rate for Payer: Cash Price |
$57.20
|
| Rate for Payer: Devoted Health Medicare |
$48.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.47
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Humana Medicare |
$44.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.00
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.00
|
| Rate for Payer: University Health Alliance Commercial |
$16.74
|
|
|
Iron Profile, Includes TIBC, Percent Saturation FSI
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS 83550
|
| Hospital Charge Code |
8117976
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: AlohaCare Medicaid |
$64.00
|
| Rate for Payer: AlohaCare Medicare |
$64.00
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Devoted Health Medicare |
$70.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.74
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Humana Medicare |
$64.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.00
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.00
|
| Rate for Payer: University Health Alliance Commercial |
$22.59
|
|
|
Iron Profile, Includes TIBC, Percent Saturation FSI
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS 83550
|
| Hospital Charge Code |
8117976
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
|
|
iron sucrose 100 mg/5ml vial [HHSC]
|
Facility
|
IP
|
$309.23
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
2500427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$262.85 |
| Max. Negotiated Rate |
$299.95 |
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$224.71
|
| Rate for Payer: Health Management Network Commercial |
$262.85
|
| Rate for Payer: Health Management Network Commercial |
$293.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$278.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.14
|
| Rate for Payer: MDX Hawaii PPO |
$335.34
|
| Rate for Payer: MDX Hawaii PPO |
$299.95
|
|
|
iron sucrose 100 mg/5ml vial [HHSC]
|
Facility
|
OP
|
$309.23
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
2500427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$299.95 |
| Rate for Payer: AlohaCare Medicaid |
$154.62
|
| Rate for Payer: AlohaCare Medicaid |
$172.85
|
| Rate for Payer: AlohaCare Medicare |
$172.85
|
| Rate for Payer: AlohaCare Medicare |
$154.62
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cash Price |
$224.71
|
| Rate for Payer: Cash Price |
$224.71
|
| Rate for Payer: Devoted Health Medicare |
$170.08
|
| Rate for Payer: Devoted Health Medicare |
$190.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$154.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$293.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$328.42
|
| Rate for Payer: Health Management Network Commercial |
$293.85
|
| Rate for Payer: Health Management Network Commercial |
$262.85
|
| Rate for Payer: Humana Medicare |
$172.85
|
| Rate for Payer: Humana Medicare |
$154.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$278.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$176.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$157.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$154.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.85
|
| Rate for Payer: MDX Hawaii PPO |
$299.95
|
| Rate for Payer: MDX Hawaii PPO |
$335.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$154.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$185.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$154.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.85
|
| Rate for Payer: University Health Alliance Commercial |
$225.40
|
| Rate for Payer: University Health Alliance Commercial |
$251.99
|
|
|
IRRIGATION .25% ACETIC ACID 1000ML CONTAINER
|
Facility
|
OP
|
$78.00
|
|
| Hospital Charge Code |
8266639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: AlohaCare Medicaid |
$39.00
|
| Rate for Payer: AlohaCare Medicare |
$39.00
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Devoted Health Medicare |
$42.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.10
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Humana Medicare |
$39.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.00
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.00
|
| Rate for Payer: University Health Alliance Commercial |
$56.85
|
|
|
IRRIGATION .25% ACETIC ACID 1000ML CONTAINER
|
Facility
|
IP
|
$78.00
|
|
| Hospital Charge Code |
8266639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
|
|
IRRIGATION .9% NACL 1000ML
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
8266621
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$6.00
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$6.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$6.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.00
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.00
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
IRRIGATION .9% NACL 1000ML
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
8266621
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
