|
traZODone 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687044301
|
| Hospital Charge Code |
2500833
|
|
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
|
|
|
traZODone 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
2500833
|
|
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
|
|
|
TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY
|
Facility
|
OP
|
$11,157.19
|
|
|
Service Code
|
CPT 59812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$11,157.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,568.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,655.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER
|
Facility
|
OP
|
$11,157.19
|
|
|
Service Code
|
CPT 59820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$11,157.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,568.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,655.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: University Health Alliance Commercial |
$11,157.19
|
|
|
Treatment of Swallowing Dysfunction Charge
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
HCPCS 92526
|
| Hospital Charge Code |
8177255
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$517.01 |
| Rate for Payer: AlohaCare Medicaid |
$266.50
|
| Rate for Payer: AlohaCare Medicare |
$266.50
|
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Devoted Health Medicare |
$293.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$266.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$506.35
|
| Rate for Payer: Health Management Network Commercial |
$453.05
|
| Rate for Payer: Humana Medicare |
$266.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$479.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$271.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$266.50
|
| Rate for Payer: MDX Hawaii PPO |
$517.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$266.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$266.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$266.50
|
| Rate for Payer: University Health Alliance Commercial |
$388.50
|
|
|
Treatment of Swallowing Dysfunction Charge
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
HCPCS 92526
|
| Hospital Charge Code |
8177255
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$453.05 |
| Max. Negotiated Rate |
$517.01 |
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Health Management Network Commercial |
$453.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$479.70
|
| Rate for Payer: MDX Hawaii PPO |
$517.01
|
|
|
Treatment of Swallowing Dysfunction Charge
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
HCPCS 92526 GP,CQ
|
| Hospital Charge Code |
8171650
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$517.01 |
| Rate for Payer: AlohaCare Medicaid |
$266.50
|
| Rate for Payer: AlohaCare Medicare |
$266.50
|
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Devoted Health Medicare |
$293.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$266.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$506.35
|
| Rate for Payer: Health Management Network Commercial |
$453.05
|
| Rate for Payer: Humana Medicare |
$266.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$479.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$271.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$266.50
|
| Rate for Payer: MDX Hawaii PPO |
$517.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$266.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$266.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$266.50
|
| Rate for Payer: University Health Alliance Commercial |
$388.50
|
|
|
Treatment of Swallowing Dysfunction Charge
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
HCPCS 92526 GP,CQ
|
| Hospital Charge Code |
8171650
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$453.05 |
| Max. Negotiated Rate |
$517.01 |
| Rate for Payer: Cash Price |
$346.45
|
| Rate for Payer: Health Management Network Commercial |
$453.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$479.70
|
| Rate for Payer: MDX Hawaii PPO |
$517.01
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
OP
|
$32.30
|
|
|
Service Code
|
NDC 00168000415
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$31.33 |
| Rate for Payer: AlohaCare Medicaid |
$16.15
|
| Rate for Payer: AlohaCare Medicare |
$16.15
|
| Rate for Payer: Cash Price |
$20.99
|
| Rate for Payer: Devoted Health Medicare |
$17.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.68
|
| Rate for Payer: Health Management Network Commercial |
$27.45
|
| Rate for Payer: Humana Medicare |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$31.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.15
|
| Rate for Payer: University Health Alliance Commercial |
$23.54
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
IP
|
$30.58
|
|
|
Service Code
|
NDC 33342032915
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Health Management Network Commercial |
$25.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.52
|
| Rate for Payer: MDX Hawaii PPO |
$29.66
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
OP
|
$30.58
|
|
|
Service Code
|
NDC 33342032915
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: AlohaCare Medicaid |
$15.29
|
| Rate for Payer: AlohaCare Medicare |
$15.29
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Devoted Health Medicare |
$16.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.05
|
| Rate for Payer: Health Management Network Commercial |
$25.99
|
| Rate for Payer: Humana Medicare |
$15.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.29
|
| Rate for Payer: MDX Hawaii PPO |
$29.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.29
|
| Rate for Payer: University Health Alliance Commercial |
$22.29
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
IP
|
$32.41
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.55 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: Cash Price |
$21.07
|
| Rate for Payer: Health Management Network Commercial |
$27.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.17
|
| Rate for Payer: MDX Hawaii PPO |
$31.44
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
IP
|
$32.30
|
|
|
Service Code
|
NDC 00168000415
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$31.33 |
| Rate for Payer: Cash Price |
$20.99
|
| Rate for Payer: Health Management Network Commercial |
$27.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.07
|
| Rate for Payer: MDX Hawaii PPO |
$31.33
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
OP
|
$21.63
|
|
|
Service Code
|
NDC 45802006435
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.81 |
| Max. Negotiated Rate |
$20.98 |
| Rate for Payer: AlohaCare Medicaid |
$10.81
|
| Rate for Payer: AlohaCare Medicare |
$10.81
|
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Devoted Health Medicare |
$11.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.55
|
| Rate for Payer: Health Management Network Commercial |
$18.39
|
| Rate for Payer: Humana Medicare |
$10.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.81
|
| Rate for Payer: MDX Hawaii PPO |
$20.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.81
|
| Rate for Payer: University Health Alliance Commercial |
$15.77
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
OP
|
$32.41
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: AlohaCare Medicaid |
$16.20
|
| Rate for Payer: AlohaCare Medicare |
$16.20
|
| Rate for Payer: Cash Price |
$21.07
|
| Rate for Payer: Devoted Health Medicare |
$17.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.79
|
| Rate for Payer: Health Management Network Commercial |
$27.55
|
| Rate for Payer: Humana Medicare |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$31.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.20
|
| Rate for Payer: University Health Alliance Commercial |
$23.62
|
|
|
triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
IP
|
$21.63
|
|
|
Service Code
|
NDC 45802006435
|
| Hospital Charge Code |
2500837
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.39 |
| Max. Negotiated Rate |
$20.98 |
| Rate for Payer: Cash Price |
$14.06
|
| Rate for Payer: Health Management Network Commercial |
$18.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.47
|
| Rate for Payer: MDX Hawaii PPO |
$20.98
|
|
|
triamcinolone 0.1% cream 80gm [HHSC]
|
Facility
|
IP
|
$78.97
|
|
|
Service Code
|
NDC 67877025180
|
| Hospital Charge Code |
2500836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.12 |
| Max. Negotiated Rate |
$76.60 |
| Rate for Payer: Cash Price |
$51.33
|
| Rate for Payer: Health Management Network Commercial |
$67.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.07
|
| Rate for Payer: MDX Hawaii PPO |
$76.60
|
|
|
triamcinolone 0.1% cream 80gm [HHSC]
|
Facility
|
OP
|
$55.85
|
|
|
Service Code
|
NDC 45802006436
|
| Hospital Charge Code |
2500836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$54.17 |
| Rate for Payer: AlohaCare Medicaid |
$27.93
|
| Rate for Payer: AlohaCare Medicare |
$27.93
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Devoted Health Medicare |
$30.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.06
|
| Rate for Payer: Health Management Network Commercial |
$47.47
|
| Rate for Payer: Humana Medicare |
$27.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.93
|
| Rate for Payer: MDX Hawaii PPO |
$54.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.93
|
| Rate for Payer: University Health Alliance Commercial |
$40.71
|
|
|
triamcinolone 0.1% cream 80gm [HHSC]
|
Facility
|
IP
|
$55.85
|
|
|
Service Code
|
NDC 45802006436
|
| Hospital Charge Code |
2500836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$54.17 |
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Health Management Network Commercial |
$47.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.27
|
| Rate for Payer: MDX Hawaii PPO |
$54.17
|
|
|
triamcinolone 0.1% cream 80gm [HHSC]
|
Facility
|
OP
|
$78.97
|
|
|
Service Code
|
NDC 67877025180
|
| Hospital Charge Code |
2500836
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.48 |
| Max. Negotiated Rate |
$76.60 |
| Rate for Payer: AlohaCare Medicaid |
$39.48
|
| Rate for Payer: AlohaCare Medicare |
$39.48
|
| Rate for Payer: Cash Price |
$51.33
|
| Rate for Payer: Devoted Health Medicare |
$43.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.02
|
| Rate for Payer: Health Management Network Commercial |
$67.12
|
| Rate for Payer: Humana Medicare |
$39.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.48
|
| Rate for Payer: MDX Hawaii PPO |
$76.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.48
|
| Rate for Payer: University Health Alliance Commercial |
$57.56
|
|
|
triamcinolone 40 mg/mL ophth (PF) [HHSC]
|
Facility
|
OP
|
$2,498.41
|
|
|
Service Code
|
HCPCS J3300
|
| Hospital Charge Code |
2500835
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$2,423.46 |
| Rate for Payer: AlohaCare Medicaid |
$1,249.20
|
| Rate for Payer: AlohaCare Medicaid |
$309.62
|
| Rate for Payer: AlohaCare Medicare |
$309.62
|
| Rate for Payer: AlohaCare Medicare |
$1,249.20
|
| Rate for Payer: Cash Price |
$402.50
|
| Rate for Payer: Cash Price |
$1,623.97
|
| Rate for Payer: Cash Price |
$402.50
|
| Rate for Payer: Cash Price |
$1,623.97
|
| Rate for Payer: Devoted Health Medicare |
$1,374.13
|
| Rate for Payer: Devoted Health Medicare |
$340.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$309.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,249.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,373.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$588.27
|
| Rate for Payer: Health Management Network Commercial |
$526.35
|
| Rate for Payer: Health Management Network Commercial |
$2,123.65
|
| Rate for Payer: Humana Medicare |
$1,249.20
|
| Rate for Payer: Humana Medicare |
$309.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,248.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,274.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,249.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$309.62
|
| Rate for Payer: MDX Hawaii PPO |
$2,423.46
|
| Rate for Payer: MDX Hawaii PPO |
$600.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$309.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,249.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,249.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$309.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$371.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,499.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,249.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$309.62
|
| Rate for Payer: University Health Alliance Commercial |
$1,821.09
|
| Rate for Payer: University Health Alliance Commercial |
$451.36
|
|
|
triamcinolone 40 mg/mL ophth (PF) [HHSC]
|
Facility
|
IP
|
$2,498.41
|
|
|
Service Code
|
HCPCS J3300
|
| Hospital Charge Code |
2500835
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,123.65 |
| Max. Negotiated Rate |
$2,423.46 |
| Rate for Payer: Cash Price |
$1,623.97
|
| Rate for Payer: Cash Price |
$402.50
|
| Rate for Payer: Health Management Network Commercial |
$2,123.65
|
| Rate for Payer: Health Management Network Commercial |
$526.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,248.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.31
|
| Rate for Payer: MDX Hawaii PPO |
$600.65
|
| Rate for Payer: MDX Hawaii PPO |
$2,423.46
|
|
|
triamcinolone acetonide 40 mg/1ml vial [HHSC]
|
Facility
|
OP
|
$59.35
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
2500834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$57.57 |
| Rate for Payer: AlohaCare Medicaid |
$29.68
|
| Rate for Payer: AlohaCare Medicaid |
$30.82
|
| Rate for Payer: AlohaCare Medicaid |
$28.48
|
| Rate for Payer: AlohaCare Medicaid |
$30.83
|
| Rate for Payer: AlohaCare Medicare |
$30.83
|
| Rate for Payer: AlohaCare Medicare |
$28.48
|
| Rate for Payer: AlohaCare Medicare |
$29.68
|
| Rate for Payer: AlohaCare Medicare |
$30.82
|
| Rate for Payer: Cash Price |
$40.08
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cash Price |
$40.08
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cash Price |
$40.07
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$40.07
|
| Rate for Payer: Devoted Health Medicare |
$33.90
|
| Rate for Payer: Devoted Health Medicare |
$32.64
|
| Rate for Payer: Devoted Health Medicare |
$33.91
|
| Rate for Payer: Devoted Health Medicare |
$31.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.38
|
| Rate for Payer: Health Management Network Commercial |
$52.39
|
| Rate for Payer: Health Management Network Commercial |
$48.42
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Health Management Network Commercial |
$52.41
|
| Rate for Payer: Humana Medicare |
$28.48
|
| Rate for Payer: Humana Medicare |
$30.82
|
| Rate for Payer: Humana Medicare |
$29.68
|
| Rate for Payer: Humana Medicare |
$30.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.68
|
| Rate for Payer: MDX Hawaii PPO |
$59.79
|
| Rate for Payer: MDX Hawaii PPO |
$55.26
|
| Rate for Payer: MDX Hawaii PPO |
$59.81
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.68
|
| Rate for Payer: University Health Alliance Commercial |
$41.53
|
| Rate for Payer: University Health Alliance Commercial |
$43.26
|
| Rate for Payer: University Health Alliance Commercial |
$44.93
|
| Rate for Payer: University Health Alliance Commercial |
$44.94
|
|
|
triamcinolone acetonide 40 mg/1ml vial [HHSC]
|
Facility
|
IP
|
$59.35
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
2500834
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$57.57 |
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$40.08
|
| Rate for Payer: Cash Price |
$37.03
|
| Rate for Payer: Cash Price |
$40.07
|
| Rate for Payer: Health Management Network Commercial |
$48.42
|
| Rate for Payer: Health Management Network Commercial |
$52.41
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Health Management Network Commercial |
$52.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: MDX Hawaii PPO |
$59.81
|
| Rate for Payer: MDX Hawaii PPO |
$55.26
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
| Rate for Payer: MDX Hawaii PPO |
$59.79
|
|
|
TRIANGLE PLATE, 2.0MM, 8 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001594
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.72 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
