|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$79,012.10
|
|
|
Service Code
|
MSDRG 826
|
| Min. Negotiated Rate |
$79,012.10 |
| Max. Negotiated Rate |
$79,012.10 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$79,012.10
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$39,875.74
|
|
|
Service Code
|
MSDRG 828
|
| Min. Negotiated Rate |
$39,875.74 |
| Max. Negotiated Rate |
$39,875.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39,875.74
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$50,354.60
|
|
|
Service Code
|
MSDRG 829
|
| Min. Negotiated Rate |
$50,354.60 |
| Max. Negotiated Rate |
$50,354.60 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,354.60
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$50,354.60
|
|
|
Service Code
|
MSDRG 830
|
| Min. Negotiated Rate |
$50,354.60 |
| Max. Negotiated Rate |
$50,354.60 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,354.60
|
|
|
Myoglobin Urine Quantitative FSI
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 83874
|
| Hospital Charge Code |
8118002
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$73.50
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Devoted Health Medicare |
$80.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.92
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$73.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.50
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.50
|
| Rate for Payer: University Health Alliance Commercial |
$33.37
|
|
|
Myoglobin Urine Quantitative FSI
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 83874
|
| Hospital Charge Code |
8118002
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
MyoMarker 3 Profile
|
Facility
|
OP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
12539022
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$1,941.94 |
| Rate for Payer: AlohaCare Medicaid |
$1,001.00
|
| Rate for Payer: AlohaCare Medicare |
$1,001.00
|
| Rate for Payer: Cash Price |
$1,301.30
|
| Rate for Payer: Cash Price |
$1,301.30
|
| Rate for Payer: Devoted Health Medicare |
$1,101.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,001.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.53
|
| Rate for Payer: Health Management Network Commercial |
$1,701.70
|
| Rate for Payer: Humana Medicare |
$1,001.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,801.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,021.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,001.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,941.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,001.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,001.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,001.00
|
| Rate for Payer: University Health Alliance Commercial |
$29.82
|
|
|
MyoMarker 3 Profile
|
Facility
|
IP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
12539022
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$1,701.70 |
| Max. Negotiated Rate |
$1,941.94 |
| Rate for Payer: Cash Price |
$1,301.30
|
| Rate for Payer: Health Management Network Commercial |
$1,701.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,801.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,941.94
|
|
|
MYOSURE LITE TISSUE REMOVAL DEVICE
|
Facility
|
IP
|
$2,465.00
|
|
| Hospital Charge Code |
9390099
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,095.25 |
| Max. Negotiated Rate |
$2,391.05 |
| Rate for Payer: Cash Price |
$1,602.25
|
| Rate for Payer: Health Management Network Commercial |
$2,095.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,218.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,391.05
|
|
|
MYOSURE LITE TISSUE REMOVAL DEVICE
|
Facility
|
OP
|
$2,465.00
|
|
| Hospital Charge Code |
9390099
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,232.50 |
| Max. Negotiated Rate |
$2,391.05 |
| Rate for Payer: AlohaCare Medicaid |
$1,232.50
|
| Rate for Payer: AlohaCare Medicare |
$1,232.50
|
| Rate for Payer: Cash Price |
$1,602.25
|
| Rate for Payer: Devoted Health Medicare |
$1,355.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,232.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,341.75
|
| Rate for Payer: Health Management Network Commercial |
$2,095.25
|
| Rate for Payer: Humana Medicare |
$1,232.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,218.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,257.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,232.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,391.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,232.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,232.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,232.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,796.74
|
|
|
MYOSURE REACH TISSUE REMOVAL DEVICE
|
Facility
|
OP
|
$3,397.00
|
|
| Hospital Charge Code |
9390100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,698.50 |
| Max. Negotiated Rate |
$3,295.09 |
| Rate for Payer: AlohaCare Medicaid |
$1,698.50
|
| Rate for Payer: AlohaCare Medicare |
$1,698.50
|
| Rate for Payer: Cash Price |
$2,208.05
|
| Rate for Payer: Devoted Health Medicare |
$1,868.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,698.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,227.15
|
| Rate for Payer: Health Management Network Commercial |
$2,887.45
|
| Rate for Payer: Humana Medicare |
$1,698.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,057.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,732.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,698.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,295.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,698.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,698.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,698.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,476.07
|
|
|
MYOSURE REACH TISSUE REMOVAL DEVICE
|
Facility
|
IP
|
$3,397.00
|
|
| Hospital Charge Code |
9390100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,887.45 |
| Max. Negotiated Rate |
$3,295.09 |
| Rate for Payer: Cash Price |
$2,208.05
|
| Rate for Payer: Health Management Network Commercial |
$2,887.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,057.30
|
| Rate for Payer: MDX Hawaii PPO |
$3,295.09
|
|
|
MYOSURE XL TISSUE REMOVAL DEVICE (3-PACK)
|
Facility
|
IP
|
$3,566.00
|
|
| Hospital Charge Code |
10713998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,031.10 |
| Max. Negotiated Rate |
$3,459.02 |
| Rate for Payer: Cash Price |
$2,317.90
|
| Rate for Payer: Health Management Network Commercial |
$3,031.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,209.40
|
| Rate for Payer: MDX Hawaii PPO |
$3,459.02
|
|
|
MYOSURE XL TISSUE REMOVAL DEVICE (3-PACK)
|
Facility
|
OP
|
$3,566.00
|
|
| Hospital Charge Code |
10713998
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,783.00 |
| Max. Negotiated Rate |
$3,459.02 |
| Rate for Payer: AlohaCare Medicaid |
$1,783.00
|
| Rate for Payer: AlohaCare Medicare |
$1,783.00
|
| Rate for Payer: Cash Price |
$2,317.90
|
| Rate for Payer: Devoted Health Medicare |
$1,961.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,783.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,387.70
|
| Rate for Payer: Health Management Network Commercial |
$3,031.10
|
| Rate for Payer: Humana Medicare |
$1,783.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,209.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,818.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,783.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,459.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,783.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,783.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,783.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,599.26
|
|
|
nalbuphine 10 mg/1 ml ampule [HHSC]
|
Facility
|
IP
|
$15.22
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
2500572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$14.76 |
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Health Management Network Commercial |
$12.94
|
| Rate for Payer: Health Management Network Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.68
|
| Rate for Payer: MDX Hawaii PPO |
$20.13
|
| Rate for Payer: MDX Hawaii PPO |
$14.76
|
|
|
nalbuphine 10 mg/1 ml ampule [HHSC]
|
Facility
|
OP
|
$15.22
|
|
|
Service Code
|
HCPCS J2300
|
| Hospital Charge Code |
2500572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.76 |
| Rate for Payer: AlohaCare Medicaid |
$7.61
|
| Rate for Payer: AlohaCare Medicaid |
$10.38
|
| Rate for Payer: AlohaCare Medicare |
$10.38
|
| Rate for Payer: AlohaCare Medicare |
$7.61
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Devoted Health Medicare |
$8.37
|
| Rate for Payer: Devoted Health Medicare |
$11.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.71
|
| Rate for Payer: Health Management Network Commercial |
$17.64
|
| Rate for Payer: Health Management Network Commercial |
$12.94
|
| Rate for Payer: Humana Medicare |
$10.38
|
| Rate for Payer: Humana Medicare |
$7.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.38
|
| Rate for Payer: MDX Hawaii PPO |
$14.76
|
| Rate for Payer: MDX Hawaii PPO |
$20.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.38
|
| Rate for Payer: University Health Alliance Commercial |
$11.09
|
| Rate for Payer: University Health Alliance Commercial |
$15.12
|
|
|
naloxone 0.4 mg/1 ml vial [HHSC]
|
Facility
|
OP
|
$27.62
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
2500574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: AlohaCare Medicaid |
$13.81
|
| Rate for Payer: AlohaCare Medicaid |
$48.20
|
| Rate for Payer: AlohaCare Medicaid |
$59.37
|
| Rate for Payer: AlohaCare Medicaid |
$40.32
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicaid |
$47.12
|
| Rate for Payer: AlohaCare Medicaid |
$48.17
|
| Rate for Payer: AlohaCare Medicare |
$47.12
|
| Rate for Payer: AlohaCare Medicare |
$48.17
|
| Rate for Payer: AlohaCare Medicare |
$48.20
|
| Rate for Payer: AlohaCare Medicare |
$13.81
|
| Rate for Payer: AlohaCare Medicare |
$40.32
|
| Rate for Payer: AlohaCare Medicare |
$59.37
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cash Price |
$52.42
|
| Rate for Payer: Cash Price |
$17.95
|
| Rate for Payer: Cash Price |
$77.17
|
| Rate for Payer: Cash Price |
$17.95
|
| Rate for Payer: Cash Price |
$77.17
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: Cash Price |
$52.42
|
| Rate for Payer: Devoted Health Medicare |
$53.02
|
| Rate for Payer: Devoted Health Medicare |
$52.99
|
| Rate for Payer: Devoted Health Medicare |
$51.83
|
| Rate for Payer: Devoted Health Medicare |
$44.35
|
| Rate for Payer: Devoted Health Medicare |
$65.30
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Devoted Health Medicare |
$15.19
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.58
|
| Rate for Payer: Health Management Network Commercial |
$81.90
|
| Rate for Payer: Health Management Network Commercial |
$80.10
|
| Rate for Payer: Health Management Network Commercial |
$81.94
|
| Rate for Payer: Health Management Network Commercial |
$68.54
|
| Rate for Payer: Health Management Network Commercial |
$23.48
|
| Rate for Payer: Health Management Network Commercial |
$100.92
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Humana Medicare |
$40.32
|
| Rate for Payer: Humana Medicare |
$48.20
|
| Rate for Payer: Humana Medicare |
$48.17
|
| Rate for Payer: Humana Medicare |
$13.81
|
| Rate for Payer: Humana Medicare |
$59.37
|
| Rate for Payer: Humana Medicare |
$47.12
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.37
|
| Rate for Payer: MDX Hawaii PPO |
$115.17
|
| Rate for Payer: MDX Hawaii PPO |
$93.51
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$78.22
|
| Rate for Payer: MDX Hawaii PPO |
$93.46
|
| Rate for Payer: MDX Hawaii PPO |
$91.40
|
| Rate for Payer: MDX Hawaii PPO |
$26.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.81
|
| Rate for Payer: University Health Alliance Commercial |
$68.68
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$86.54
|
| Rate for Payer: University Health Alliance Commercial |
$70.23
|
| Rate for Payer: University Health Alliance Commercial |
$58.78
|
| Rate for Payer: University Health Alliance Commercial |
$20.13
|
| Rate for Payer: University Health Alliance Commercial |
$70.27
|
|
|
naloxone 0.4 mg/1 ml vial [HHSC]
|
Facility
|
IP
|
$118.73
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
2500574
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.92 |
| Max. Negotiated Rate |
$115.17 |
| Rate for Payer: Cash Price |
$77.17
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cash Price |
$52.42
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cash Price |
$17.95
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: Health Management Network Commercial |
$81.90
|
| Rate for Payer: Health Management Network Commercial |
$23.48
|
| Rate for Payer: Health Management Network Commercial |
$81.94
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$100.92
|
| Rate for Payer: Health Management Network Commercial |
$68.54
|
| Rate for Payer: Health Management Network Commercial |
$80.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.76
|
| Rate for Payer: MDX Hawaii PPO |
$78.22
|
| Rate for Payer: MDX Hawaii PPO |
$115.17
|
| Rate for Payer: MDX Hawaii PPO |
$26.79
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$91.40
|
| Rate for Payer: MDX Hawaii PPO |
$93.46
|
| Rate for Payer: MDX Hawaii PPO |
$93.51
|
|
|
naloxone 2 mg/2 ml syringe [HHSC]
|
Facility
|
OP
|
$175.40
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
2500575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$170.14 |
| Rate for Payer: AlohaCare Medicaid |
$87.70
|
| Rate for Payer: AlohaCare Medicaid |
$91.84
|
| Rate for Payer: AlohaCare Medicaid |
$88.08
|
| Rate for Payer: AlohaCare Medicare |
$88.08
|
| Rate for Payer: AlohaCare Medicare |
$87.70
|
| Rate for Payer: AlohaCare Medicare |
$91.84
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$119.39
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.01
|
| Rate for Payer: Cash Price |
$114.01
|
| Rate for Payer: Cash Price |
$119.39
|
| Rate for Payer: Devoted Health Medicare |
$96.47
|
| Rate for Payer: Devoted Health Medicare |
$101.02
|
| Rate for Payer: Devoted Health Medicare |
$96.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$167.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$166.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.50
|
| Rate for Payer: Health Management Network Commercial |
$156.13
|
| Rate for Payer: Health Management Network Commercial |
$149.09
|
| Rate for Payer: Health Management Network Commercial |
$149.73
|
| Rate for Payer: Humana Medicare |
$87.70
|
| Rate for Payer: Humana Medicare |
$88.08
|
| Rate for Payer: Humana Medicare |
$91.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$158.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.84
|
| Rate for Payer: MDX Hawaii PPO |
$178.17
|
| Rate for Payer: MDX Hawaii PPO |
$170.87
|
| Rate for Payer: MDX Hawaii PPO |
$170.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$105.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$105.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$110.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$127.85
|
| Rate for Payer: University Health Alliance Commercial |
$128.40
|
| Rate for Payer: University Health Alliance Commercial |
$133.88
|
|
|
naloxone 2 mg/2 ml syringe [HHSC]
|
Facility
|
IP
|
$183.68
|
|
|
Service Code
|
HCPCS J2312
|
| Hospital Charge Code |
2500575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.13 |
| Max. Negotiated Rate |
$178.17 |
| Rate for Payer: Cash Price |
$119.39
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.01
|
| Rate for Payer: Health Management Network Commercial |
$149.09
|
| Rate for Payer: Health Management Network Commercial |
$156.13
|
| Rate for Payer: Health Management Network Commercial |
$149.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$158.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.86
|
| Rate for Payer: MDX Hawaii PPO |
$170.87
|
| Rate for Payer: MDX Hawaii PPO |
$170.14
|
| Rate for Payer: MDX Hawaii PPO |
$178.17
|
|
|
naloxone 4 mg/0.1 mL nasal spray [HHSC]
|
Facility
|
IP
|
$130.99
|
|
|
Service Code
|
NDC 69547062702
|
| Hospital Charge Code |
2501149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.34 |
| Max. Negotiated Rate |
$127.06 |
| Rate for Payer: Cash Price |
$85.14
|
| Rate for Payer: Health Management Network Commercial |
$111.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.89
|
| Rate for Payer: MDX Hawaii PPO |
$127.06
|
|
|
naloxone 4 mg/0.1 mL nasal spray [HHSC]
|
Facility
|
OP
|
$130.99
|
|
|
Service Code
|
NDC 69547062702
|
| Hospital Charge Code |
2501149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.50 |
| Max. Negotiated Rate |
$127.06 |
| Rate for Payer: AlohaCare Medicaid |
$65.50
|
| Rate for Payer: AlohaCare Medicare |
$65.50
|
| Rate for Payer: Cash Price |
$85.14
|
| Rate for Payer: Devoted Health Medicare |
$72.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.44
|
| Rate for Payer: Health Management Network Commercial |
$111.34
|
| Rate for Payer: Humana Medicare |
$65.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.50
|
| Rate for Payer: MDX Hawaii PPO |
$127.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.50
|
| Rate for Payer: University Health Alliance Commercial |
$95.48
|
|
|
naphazo-pheniram 0.025-0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$53.61
|
|
|
Service Code
|
NDC 00065008515
|
| Hospital Charge Code |
2500576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
|
|
naphazo-pheniram 0.025-0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$53.61
|
|
|
Service Code
|
NDC 00065008515
|
| Hospital Charge Code |
2500576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.80 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: AlohaCare Medicaid |
$26.80
|
| Rate for Payer: AlohaCare Medicare |
$26.80
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Devoted Health Medicare |
$29.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.93
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Humana Medicare |
$26.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.80
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.80
|
| Rate for Payer: University Health Alliance Commercial |
$39.08
|
|
|
Nasogastric (NG) Tube Insertion
|
Facility
|
OP
|
$779.00
|
|
|
Service Code
|
HCPCS 43752
|
| Hospital Charge Code |
607644
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.91 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: AlohaCare Medicaid |
$389.50
|
| Rate for Payer: AlohaCare Medicare |
$389.50
|
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Devoted Health Medicare |
$428.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$570.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$389.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$740.05
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Humana Medicare |
$389.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$397.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$389.50
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$389.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$389.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$389.50
|
| Rate for Payer: University Health Alliance Commercial |
$567.81
|
|
