|
OB Check Level 5 Charge
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
HCPCS 99215
|
| Hospital Charge Code |
8140432
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$689.67 |
| Rate for Payer: AlohaCare Medicaid |
$355.50
|
| Rate for Payer: AlohaCare Medicare |
$355.50
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Devoted Health Medicare |
$391.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$355.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$675.45
|
| Rate for Payer: Health Management Network Commercial |
$604.35
|
| Rate for Payer: Humana Medicare |
$355.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$639.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$362.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$355.50
|
| Rate for Payer: MDX Hawaii PPO |
$689.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$355.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$355.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$355.50
|
| Rate for Payer: University Health Alliance Commercial |
$518.25
|
|
|
OB Check Level 5 Charge
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
HCPCS 99215
|
| Hospital Charge Code |
8140432
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$604.35 |
| Max. Negotiated Rate |
$689.67 |
| Rate for Payer: Cash Price |
$462.15
|
| Rate for Payer: Health Management Network Commercial |
$604.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$639.90
|
| Rate for Payer: MDX Hawaii PPO |
$689.67
|
|
|
Occult Blood, Fecal, ICT FSI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
8118004
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$86.50
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Devoted Health Medicare |
$95.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13.33
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.92
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$86.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.50
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.50
|
| Rate for Payer: University Health Alliance Commercial |
$41.11
|
|
|
Occult Blood, Fecal, ICT FSI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
8118004
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
Occult Blood FSI
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
8228903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
Occult Blood FSI
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
HCPCS 82272
|
| Hospital Charge Code |
8228903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: AlohaCare Medicaid |
$23.00
|
| Rate for Payer: AlohaCare Medicare |
$23.00
|
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Devoted Health Medicare |
$25.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.54
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.23
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Humana Medicare |
$23.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.00
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.00
|
| Rate for Payer: University Health Alliance Commercial |
$8.40
|
|
|
Occult Blood Stool POC
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS 82272 QW
|
| Hospital Charge Code |
607610
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
|
|
Occult Blood Stool POC
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 82272 QW
|
| Hospital Charge Code |
607610
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicare |
$18.50
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Devoted Health Medicare |
$20.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.15
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Humana Medicare |
$18.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.50
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.50
|
| Rate for Payer: University Health Alliance Commercial |
$8.40
|
|
|
octreotide 500 mcg/ml vial [HHSC]
|
Facility
|
OP
|
$201.02
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
2500599
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$194.99 |
| Rate for Payer: AlohaCare Medicaid |
$100.51
|
| Rate for Payer: AlohaCare Medicaid |
$153.97
|
| Rate for Payer: AlohaCare Medicaid |
$96.86
|
| Rate for Payer: AlohaCare Medicare |
$153.97
|
| Rate for Payer: AlohaCare Medicare |
$100.51
|
| Rate for Payer: AlohaCare Medicare |
$96.86
|
| Rate for Payer: Cash Price |
$200.16
|
| Rate for Payer: Cash Price |
$130.66
|
| Rate for Payer: Cash Price |
$125.91
|
| Rate for Payer: Cash Price |
$125.91
|
| Rate for Payer: Cash Price |
$200.16
|
| Rate for Payer: Cash Price |
$130.66
|
| Rate for Payer: Devoted Health Medicare |
$169.37
|
| Rate for Payer: Devoted Health Medicare |
$110.56
|
| Rate for Payer: Devoted Health Medicare |
$106.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$292.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$184.02
|
| Rate for Payer: Health Management Network Commercial |
$261.75
|
| Rate for Payer: Health Management Network Commercial |
$164.65
|
| Rate for Payer: Health Management Network Commercial |
$170.87
|
| Rate for Payer: Humana Medicare |
$153.97
|
| Rate for Payer: Humana Medicare |
$100.51
|
| Rate for Payer: Humana Medicare |
$96.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$277.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$157.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.97
|
| Rate for Payer: MDX Hawaii PPO |
$298.70
|
| Rate for Payer: MDX Hawaii PPO |
$194.99
|
| Rate for Payer: MDX Hawaii PPO |
$187.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.97
|
| Rate for Payer: University Health Alliance Commercial |
$141.20
|
| Rate for Payer: University Health Alliance Commercial |
$146.52
|
| Rate for Payer: University Health Alliance Commercial |
$224.46
|
|
|
octreotide 500 mcg/ml vial [HHSC]
|
Facility
|
IP
|
$307.94
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
2500599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$261.75 |
| Max. Negotiated Rate |
$298.70 |
| Rate for Payer: Cash Price |
$200.16
|
| Rate for Payer: Cash Price |
$130.66
|
| Rate for Payer: Cash Price |
$125.91
|
| Rate for Payer: Health Management Network Commercial |
$261.75
|
| Rate for Payer: Health Management Network Commercial |
$170.87
|
| Rate for Payer: Health Management Network Commercial |
$164.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$277.15
|
| Rate for Payer: MDX Hawaii PPO |
$187.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.99
|
| Rate for Payer: MDX Hawaii PPO |
$298.70
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
IP
|
$105.81
|
|
|
Service Code
|
NDC 64380017302
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.94 |
| Max. Negotiated Rate |
$102.64 |
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Health Management Network Commercial |
$89.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.23
|
| Rate for Payer: MDX Hawaii PPO |
$102.64
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
IP
|
$16.95
|
|
|
Service Code
|
NDC 55111026381
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.41 |
| Max. Negotiated Rate |
$16.44 |
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Health Management Network Commercial |
$14.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.26
|
| Rate for Payer: MDX Hawaii PPO |
$16.44
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
OP
|
$16.95
|
|
|
Service Code
|
NDC 55111026381
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$16.44 |
| Rate for Payer: AlohaCare Medicaid |
$8.47
|
| Rate for Payer: AlohaCare Medicare |
$8.47
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Devoted Health Medicare |
$9.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.10
|
| Rate for Payer: Health Management Network Commercial |
$14.41
|
| Rate for Payer: Humana Medicare |
$8.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.47
|
| Rate for Payer: MDX Hawaii PPO |
$16.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.47
|
| Rate for Payer: University Health Alliance Commercial |
$12.35
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
OP
|
$105.81
|
|
|
Service Code
|
NDC 49884032155
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.91 |
| Max. Negotiated Rate |
$102.64 |
| Rate for Payer: AlohaCare Medicaid |
$52.91
|
| Rate for Payer: AlohaCare Medicare |
$52.91
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Devoted Health Medicare |
$58.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.52
|
| Rate for Payer: Health Management Network Commercial |
$89.94
|
| Rate for Payer: Humana Medicare |
$52.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.91
|
| Rate for Payer: MDX Hawaii PPO |
$102.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.91
|
| Rate for Payer: University Health Alliance Commercial |
$77.12
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
OP
|
$105.81
|
|
|
Service Code
|
NDC 64380017302
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.91 |
| Max. Negotiated Rate |
$102.64 |
| Rate for Payer: AlohaCare Medicaid |
$52.91
|
| Rate for Payer: AlohaCare Medicare |
$52.91
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Devoted Health Medicare |
$58.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.52
|
| Rate for Payer: Health Management Network Commercial |
$89.94
|
| Rate for Payer: Humana Medicare |
$52.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.91
|
| Rate for Payer: MDX Hawaii PPO |
$102.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.91
|
| Rate for Payer: University Health Alliance Commercial |
$77.12
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
IP
|
$105.81
|
|
|
Service Code
|
NDC 49884032155
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.94 |
| Max. Negotiated Rate |
$102.64 |
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Health Management Network Commercial |
$89.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.23
|
| Rate for Payer: MDX Hawaii PPO |
$102.64
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
IP
|
$105.82
|
|
|
Service Code
|
NDC 59746030732
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.95 |
| Max. Negotiated Rate |
$102.65 |
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Health Management Network Commercial |
$89.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.24
|
| Rate for Payer: MDX Hawaii PPO |
$102.65
|
|
|
OLANZapine 10 mg ODT [HHSC]
|
Facility
|
OP
|
$105.82
|
|
|
Service Code
|
NDC 59746030732
|
| Hospital Charge Code |
2500605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.91 |
| Max. Negotiated Rate |
$102.65 |
| Rate for Payer: AlohaCare Medicaid |
$52.91
|
| Rate for Payer: AlohaCare Medicare |
$52.91
|
| Rate for Payer: Cash Price |
$68.78
|
| Rate for Payer: Devoted Health Medicare |
$58.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.53
|
| Rate for Payer: Health Management Network Commercial |
$89.95
|
| Rate for Payer: Humana Medicare |
$52.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.91
|
| Rate for Payer: MDX Hawaii PPO |
$102.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.91
|
| Rate for Payer: University Health Alliance Commercial |
$77.13
|
|
|
OLANZapine 10 mg vial [HHSC]
|
Facility
|
OP
|
$195.93
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2500606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.97 |
| Max. Negotiated Rate |
$190.05 |
| Rate for Payer: Ohana Health Plan Medicare |
$95.81
|
| Rate for Payer: AlohaCare Medicaid |
$97.97
|
| Rate for Payer: AlohaCare Medicaid |
$95.81
|
| Rate for Payer: AlohaCare Medicaid |
$95.29
|
| Rate for Payer: AlohaCare Medicaid |
$155.16
|
| Rate for Payer: AlohaCare Medicare |
$97.97
|
| Rate for Payer: AlohaCare Medicare |
$155.16
|
| Rate for Payer: AlohaCare Medicare |
$95.81
|
| Rate for Payer: AlohaCare Medicare |
$95.29
|
| Rate for Payer: Cash Price |
$127.35
|
| Rate for Payer: Cash Price |
$123.88
|
| Rate for Payer: Cash Price |
$201.70
|
| Rate for Payer: Cash Price |
$124.55
|
| Rate for Payer: Devoted Health Medicare |
$105.39
|
| Rate for Payer: Devoted Health Medicare |
$107.76
|
| Rate for Payer: Devoted Health Medicare |
$170.67
|
| Rate for Payer: Devoted Health Medicare |
$104.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$181.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$186.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$182.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$294.79
|
| Rate for Payer: Health Management Network Commercial |
$263.76
|
| Rate for Payer: Health Management Network Commercial |
$162.88
|
| Rate for Payer: Health Management Network Commercial |
$166.54
|
| Rate for Payer: Health Management Network Commercial |
$161.99
|
| Rate for Payer: Humana Medicare |
$155.16
|
| Rate for Payer: Humana Medicare |
$95.81
|
| Rate for Payer: Humana Medicare |
$97.97
|
| Rate for Payer: Humana Medicare |
$95.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$176.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$97.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$97.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.16
|
| Rate for Payer: MDX Hawaii PPO |
$301.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.86
|
| Rate for Payer: MDX Hawaii PPO |
$185.87
|
| Rate for Payer: MDX Hawaii PPO |
$190.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$186.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$117.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.29
|
| Rate for Payer: University Health Alliance Commercial |
$226.18
|
| Rate for Payer: University Health Alliance Commercial |
$138.91
|
| Rate for Payer: University Health Alliance Commercial |
$139.67
|
| Rate for Payer: University Health Alliance Commercial |
$142.81
|
|
|
OLANZapine 10 mg vial [HHSC]
|
Facility
|
IP
|
$191.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2500606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$162.88 |
| Max. Negotiated Rate |
$185.87 |
| Rate for Payer: Cash Price |
$124.55
|
| Rate for Payer: Cash Price |
$201.70
|
| Rate for Payer: Cash Price |
$123.88
|
| Rate for Payer: Cash Price |
$127.35
|
| Rate for Payer: Health Management Network Commercial |
$161.99
|
| Rate for Payer: Health Management Network Commercial |
$263.76
|
| Rate for Payer: Health Management Network Commercial |
$162.88
|
| Rate for Payer: Health Management Network Commercial |
$166.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$176.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.46
|
| Rate for Payer: MDX Hawaii PPO |
$301.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.86
|
| Rate for Payer: MDX Hawaii PPO |
$185.87
|
| Rate for Payer: MDX Hawaii PPO |
$190.05
|
|
|
Olanzapine and Metabolite
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12516678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$297.50 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Health Management Network Commercial |
$297.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.00
|
| Rate for Payer: MDX Hawaii PPO |
$339.50
|
|
|
Olanzapine and Metabolite
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12516678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: AlohaCare Medicaid |
$175.00
|
| Rate for Payer: AlohaCare Medicare |
$175.00
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Devoted Health Medicare |
$192.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$297.50
|
| Rate for Payer: Humana Medicare |
$175.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$178.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.00
|
| Rate for Payer: MDX Hawaii PPO |
$339.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.00
|
| Rate for Payer: University Health Alliance Commercial |
$35.39
|
|
|
Olanzapine Level FSI
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12220757
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
|
|
Olanzapine Level FSI
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12220757
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: AlohaCare Medicaid |
$184.00
|
| Rate for Payer: AlohaCare Medicare |
$184.00
|
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Devoted Health Medicare |
$202.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$184.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Humana Medicare |
$184.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$187.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$184.00
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$184.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$184.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$184.00
|
| Rate for Payer: University Health Alliance Commercial |
$35.39
|
|
|
Omidria/BSS 500mL cmpd [HHSC]
|
Facility
|
OP
|
$1,408.22
|
|
|
Service Code
|
NDC 99999999949
|
| Hospital Charge Code |
2500997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$704.11 |
| Max. Negotiated Rate |
$1,365.97 |
| Rate for Payer: AlohaCare Medicaid |
$704.11
|
| Rate for Payer: AlohaCare Medicare |
$704.11
|
| Rate for Payer: Cash Price |
$915.34
|
| Rate for Payer: Devoted Health Medicare |
$774.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$704.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,337.81
|
| Rate for Payer: Health Management Network Commercial |
$1,196.99
|
| Rate for Payer: Humana Medicare |
$704.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$718.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$704.11
|
| Rate for Payer: MDX Hawaii PPO |
$1,365.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$704.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$704.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$844.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$704.11
|
| Rate for Payer: University Health Alliance Commercial |
$1,026.45
|
|
