|
Monkeypox Virus PCR FSI
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 87593
|
| Hospital Charge Code |
10594219
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
Monkeypox Virus PCR FSI
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 87593
|
| Hospital Charge Code |
10594219
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: AlohaCare Medicaid |
$59.00
|
| Rate for Payer: AlohaCare Medicare |
$59.00
|
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Devoted Health Medicare |
$64.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Humana Medicare |
$59.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.00
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.00
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
montelukast 10 mg tablet [HHSC]
|
Facility
|
IP
|
$30.62
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
2500558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.03 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Health Management Network Commercial |
$26.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.56
|
| Rate for Payer: MDX Hawaii PPO |
$29.70
|
|
|
montelukast 10 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
2500558
|
|
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
|
|
|
montelukast 10 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
2500558
|
|
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
|
|
|
montelukast 10 mg tablet [HHSC]
|
Facility
|
OP
|
$30.62
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
2500558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: AlohaCare Medicaid |
$15.31
|
| Rate for Payer: AlohaCare Medicare |
$15.31
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Devoted Health Medicare |
$16.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.09
|
| Rate for Payer: Health Management Network Commercial |
$26.03
|
| Rate for Payer: Humana Medicare |
$15.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.31
|
| Rate for Payer: MDX Hawaii PPO |
$29.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$22.32
|
|
|
MORGAN LENS MEDI-FLOW
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS V2797
|
| Hospital Charge Code |
8500833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$75.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Devoted Health Medicare |
$82.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$75.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.00
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
|
|
MORGAN LENS MEDI-FLOW
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS V2797
|
| Hospital Charge Code |
8500833
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
|
|
morphine 1000 mg/20 ml (PF) vial [HHSC]
|
Facility
|
OP
|
$677.97
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2501007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$657.63 |
| Rate for Payer: AlohaCare Medicaid |
$338.99
|
| Rate for Payer: AlohaCare Medicare |
$338.99
|
| Rate for Payer: Cash Price |
$440.68
|
| Rate for Payer: Cash Price |
$440.68
|
| Rate for Payer: Devoted Health Medicare |
$372.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$338.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$644.07
|
| Rate for Payer: Health Management Network Commercial |
$576.27
|
| Rate for Payer: Humana Medicare |
$338.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$610.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$345.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$338.99
|
| Rate for Payer: MDX Hawaii PPO |
$657.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$338.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$338.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$406.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$338.99
|
| Rate for Payer: University Health Alliance Commercial |
$494.17
|
|
|
morphine 1000 mg/20 ml (PF) vial [HHSC]
|
Facility
|
IP
|
$677.97
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2501007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$576.27 |
| Max. Negotiated Rate |
$657.63 |
| Rate for Payer: Cash Price |
$440.68
|
| Rate for Payer: Health Management Network Commercial |
$576.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$610.17
|
| Rate for Payer: MDX Hawaii PPO |
$657.63
|
|
|
morphine 10 mg/0.5 mL oral soln U/D [HHSC]
|
Facility
|
IP
|
$19.75
|
|
|
Service Code
|
NDC 68094004558
|
| Hospital Charge Code |
2501173
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.79 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Health Management Network Commercial |
$16.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.77
|
| Rate for Payer: MDX Hawaii PPO |
$19.16
|
|
|
morphine 10 mg/0.5 mL oral soln U/D [HHSC]
|
Facility
|
OP
|
$19.75
|
|
|
Service Code
|
NDC 68094004558
|
| Hospital Charge Code |
2501173
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: AlohaCare Medicaid |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Devoted Health Medicare |
$10.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.76
|
| Rate for Payer: Health Management Network Commercial |
$16.79
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: MDX Hawaii PPO |
$19.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: University Health Alliance Commercial |
$14.40
|
|
|
morphine 10 mg/1ml (PF) injection [HHSC]
|
Facility
|
IP
|
$12.42
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$10.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.52
|
| Rate for Payer: MDX Hawaii PPO |
$12.42
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
|
|
morphine 10 mg/1ml (PF) injection [HHSC]
|
Facility
|
OP
|
$12.42
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500561
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: AlohaCare Medicaid |
$6.21
|
| Rate for Payer: AlohaCare Medicaid |
$6.40
|
| Rate for Payer: AlohaCare Medicare |
$6.40
|
| Rate for Payer: AlohaCare Medicare |
$6.21
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Devoted Health Medicare |
$6.83
|
| Rate for Payer: Devoted Health Medicare |
$7.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.16
|
| Rate for Payer: Health Management Network Commercial |
$10.88
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Humana Medicare |
$6.21
|
| Rate for Payer: Humana Medicare |
$6.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.40
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.40
|
| Rate for Payer: University Health Alliance Commercial |
$9.05
|
| Rate for Payer: University Health Alliance Commercial |
$9.33
|
|
|
morphine 2 mg/1 ml (PF) injection [HHSC]
|
Facility
|
IP
|
$19.15
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500563
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$18.58 |
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$16.28
|
| Rate for Payer: Health Management Network Commercial |
$16.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: MDX Hawaii PPO |
$18.56
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: MDX Hawaii PPO |
$18.58
|
|
|
morphine 2 mg/1 ml (PF) injection [HHSC]
|
Facility
|
OP
|
$12.42
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500563
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: MDX Hawaii PPO |
$18.58
|
| Rate for Payer: AlohaCare Medicaid |
$6.21
|
| Rate for Payer: AlohaCare Medicaid |
$9.57
|
| Rate for Payer: AlohaCare Medicaid |
$9.56
|
| Rate for Payer: AlohaCare Medicare |
$9.56
|
| Rate for Payer: AlohaCare Medicare |
$6.21
|
| Rate for Payer: AlohaCare Medicare |
$9.57
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$12.45
|
| Rate for Payer: Devoted Health Medicare |
$6.83
|
| Rate for Payer: Devoted Health Medicare |
$10.53
|
| Rate for Payer: Devoted Health Medicare |
$10.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.19
|
| Rate for Payer: Health Management Network Commercial |
$16.28
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$16.26
|
| Rate for Payer: Humana Medicare |
$6.21
|
| Rate for Payer: Humana Medicare |
$9.56
|
| Rate for Payer: Humana Medicare |
$9.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.57
|
| Rate for Payer: MDX Hawaii PPO |
$18.56
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.57
|
| Rate for Payer: University Health Alliance Commercial |
$9.05
|
| Rate for Payer: University Health Alliance Commercial |
$13.94
|
| Rate for Payer: University Health Alliance Commercial |
$13.96
|
|
|
morphine 4 mg/1 ml (PF) injection [HHSC]
|
Facility
|
IP
|
$12.42
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$10.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.29
|
| Rate for Payer: MDX Hawaii PPO |
$12.17
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
|
|
morphine 4 mg/1 ml (PF) injection [HHSC]
|
Facility
|
OP
|
$12.42
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
2500565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: AlohaCare Medicaid |
$6.21
|
| Rate for Payer: AlohaCare Medicaid |
$6.28
|
| Rate for Payer: AlohaCare Medicare |
$6.28
|
| Rate for Payer: AlohaCare Medicare |
$6.21
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Devoted Health Medicare |
$6.83
|
| Rate for Payer: Devoted Health Medicare |
$6.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.92
|
| Rate for Payer: Health Management Network Commercial |
$10.67
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Humana Medicare |
$6.21
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.28
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.28
|
| Rate for Payer: University Health Alliance Commercial |
$9.05
|
| Rate for Payer: University Health Alliance Commercial |
$9.15
|
|
|
morphine (PF) 10 mg/10 ml ampule [HHSC]
|
Facility
|
IP
|
$163.41
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
2500559
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.90 |
| Max. Negotiated Rate |
$158.51 |
| Rate for Payer: Cash Price |
$106.22
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Health Management Network Commercial |
$138.90
|
| Rate for Payer: Health Management Network Commercial |
$53.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.48
|
| Rate for Payer: MDX Hawaii PPO |
$60.87
|
| Rate for Payer: MDX Hawaii PPO |
$158.51
|
|
|
morphine (PF) 10 mg/10 ml ampule [HHSC]
|
Facility
|
OP
|
$163.41
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
2500559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$158.51 |
| Rate for Payer: AlohaCare Medicaid |
$81.70
|
| Rate for Payer: AlohaCare Medicaid |
$31.38
|
| Rate for Payer: AlohaCare Medicare |
$31.38
|
| Rate for Payer: AlohaCare Medicare |
$81.70
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Cash Price |
$106.22
|
| Rate for Payer: Cash Price |
$106.22
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Devoted Health Medicare |
$89.88
|
| Rate for Payer: Devoted Health Medicare |
$34.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.61
|
| Rate for Payer: Health Management Network Commercial |
$53.34
|
| Rate for Payer: Health Management Network Commercial |
$138.90
|
| Rate for Payer: Humana Medicare |
$81.70
|
| Rate for Payer: Humana Medicare |
$31.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.38
|
| Rate for Payer: MDX Hawaii PPO |
$158.51
|
| Rate for Payer: MDX Hawaii PPO |
$60.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.38
|
| Rate for Payer: University Health Alliance Commercial |
$119.11
|
| Rate for Payer: University Health Alliance Commercial |
$45.74
|
|
|
MOUTH PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$64,300.91
|
|
|
Service Code
|
MSDRG 137
|
| Min. Negotiated Rate |
$64,300.91 |
| Max. Negotiated Rate |
$64,300.91 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64,300.91
|
|
|
MOUTH PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$34,164.64
|
|
|
Service Code
|
MSDRG 138
|
| Min. Negotiated Rate |
$34,164.64 |
| Max. Negotiated Rate |
$34,164.64 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34,164.64
|
|
|
moxifloxacin 0.5% ophth 3ml [HHSC]
|
Facility
|
OP
|
$591.76
|
|
|
Service Code
|
NDC 65862084003
|
| Hospital Charge Code |
2500567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$295.88 |
| Max. Negotiated Rate |
$574.01 |
| Rate for Payer: AlohaCare Medicaid |
$295.88
|
| Rate for Payer: AlohaCare Medicare |
$295.88
|
| Rate for Payer: Cash Price |
$384.64
|
| Rate for Payer: Devoted Health Medicare |
$325.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$295.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$562.17
|
| Rate for Payer: Health Management Network Commercial |
$503.00
|
| Rate for Payer: Humana Medicare |
$295.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$301.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$295.88
|
| Rate for Payer: MDX Hawaii PPO |
$574.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$295.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$295.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$355.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$295.88
|
| Rate for Payer: University Health Alliance Commercial |
$431.33
|
|
|
moxifloxacin 0.5% ophth 3ml [HHSC]
|
Facility
|
IP
|
$591.76
|
|
|
Service Code
|
NDC 60505058204
|
| Hospital Charge Code |
2500567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$503.00 |
| Max. Negotiated Rate |
$574.01 |
| Rate for Payer: Cash Price |
$384.64
|
| Rate for Payer: Health Management Network Commercial |
$503.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.58
|
| Rate for Payer: MDX Hawaii PPO |
$574.01
|
|
|
moxifloxacin 0.5% ophth 3ml [HHSC]
|
Facility
|
OP
|
$591.76
|
|
|
Service Code
|
NDC 00378543035
|
| Hospital Charge Code |
2500567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$295.88 |
| Max. Negotiated Rate |
$574.01 |
| Rate for Payer: AlohaCare Medicaid |
$295.88
|
| Rate for Payer: AlohaCare Medicare |
$295.88
|
| Rate for Payer: Cash Price |
$384.64
|
| Rate for Payer: Devoted Health Medicare |
$325.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$295.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$562.17
|
| Rate for Payer: Health Management Network Commercial |
$503.00
|
| Rate for Payer: Humana Medicare |
$295.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$301.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$295.88
|
| Rate for Payer: MDX Hawaii PPO |
$574.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$295.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$295.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$355.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$295.88
|
| Rate for Payer: University Health Alliance Commercial |
$431.33
|
|
