|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
IP
|
$87.96
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Health Management Network Commercial |
$74.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.16
|
| Rate for Payer: MDX Hawaii PPO |
$85.32
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
OP
|
$87.96
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.98 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: AlohaCare Medicaid |
$43.98
|
| Rate for Payer: AlohaCare Medicare |
$43.98
|
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Devoted Health Medicare |
$48.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.56
|
| Rate for Payer: Health Management Network Commercial |
$74.77
|
| Rate for Payer: Humana Medicare |
$43.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.98
|
| Rate for Payer: MDX Hawaii PPO |
$85.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.98
|
| Rate for Payer: University Health Alliance Commercial |
$64.11
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
IP
|
$142.25
|
|
|
Service Code
|
NDC 66689020204
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.91 |
| Max. Negotiated Rate |
$137.98 |
| Rate for Payer: Cash Price |
$92.46
|
| Rate for Payer: Health Management Network Commercial |
$120.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.03
|
| Rate for Payer: MDX Hawaii PPO |
$137.98
|
|
|
ACTIVATION TOOL
|
Facility
|
IP
|
$219.00
|
|
| Hospital Charge Code |
12969391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.15 |
| Max. Negotiated Rate |
$212.43 |
| Rate for Payer: Cash Price |
$142.35
|
| Rate for Payer: Health Management Network Commercial |
$186.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$197.10
|
| Rate for Payer: MDX Hawaii PPO |
$212.43
|
|
|
ACTIVATION TOOL
|
Facility
|
OP
|
$219.00
|
|
| Hospital Charge Code |
12969391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.50 |
| Max. Negotiated Rate |
$212.43 |
| Rate for Payer: AlohaCare Medicaid |
$109.50
|
| Rate for Payer: AlohaCare Medicare |
$109.50
|
| Rate for Payer: Cash Price |
$142.35
|
| Rate for Payer: Devoted Health Medicare |
$120.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$208.05
|
| Rate for Payer: Health Management Network Commercial |
$186.15
|
| Rate for Payer: Humana Medicare |
$109.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$197.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.50
|
| Rate for Payer: MDX Hawaii PPO |
$212.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.50
|
| Rate for Payer: University Health Alliance Commercial |
$159.63
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$187.40
|
|
|
Service Code
|
NDC 66689020308
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.70 |
| Max. Negotiated Rate |
$181.78 |
| Rate for Payer: AlohaCare Medicaid |
$93.70
|
| Rate for Payer: AlohaCare Medicare |
$93.70
|
| Rate for Payer: Cash Price |
$121.81
|
| Rate for Payer: Devoted Health Medicare |
$103.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$178.03
|
| Rate for Payer: Health Management Network Commercial |
$159.29
|
| Rate for Payer: Humana Medicare |
$93.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$168.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.70
|
| Rate for Payer: MDX Hawaii PPO |
$181.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$112.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.70
|
| Rate for Payer: University Health Alliance Commercial |
$136.60
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$117.01
|
|
|
Service Code
|
NDC 00574052076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.46 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$187.40
|
|
|
Service Code
|
NDC 66689020308
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.29 |
| Max. Negotiated Rate |
$181.78 |
| Rate for Payer: Cash Price |
$121.81
|
| Rate for Payer: Health Management Network Commercial |
$159.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$168.66
|
| Rate for Payer: MDX Hawaii PPO |
$181.78
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$117.01
|
|
|
Service Code
|
NDC 00574052076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.51 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: AlohaCare Medicaid |
$58.51
|
| Rate for Payer: AlohaCare Medicare |
$58.51
|
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Devoted Health Medicare |
$64.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.16
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Humana Medicare |
$58.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.51
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.51
|
| Rate for Payer: University Health Alliance Commercial |
$85.29
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$117.01
|
|
|
Service Code
|
NDC 00574012076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.46 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$117.01
|
|
|
Service Code
|
NDC 00574012076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.51 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: AlohaCare Medicaid |
$58.51
|
| Rate for Payer: AlohaCare Medicare |
$58.51
|
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Devoted Health Medicare |
$64.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.16
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Humana Medicare |
$58.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.51
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.51
|
| Rate for Payer: University Health Alliance Commercial |
$85.29
|
|
|
ACUMEN IQ ADJUSTABLE CUFF
|
Facility
|
OP
|
$1,523.00
|
|
| Hospital Charge Code |
10526812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$761.50 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: AlohaCare Medicaid |
$761.50
|
| Rate for Payer: AlohaCare Medicare |
$761.50
|
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Devoted Health Medicare |
$837.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$761.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,446.85
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Humana Medicare |
$761.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$776.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$761.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$761.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$761.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$761.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,110.11
|
|
|
ACUMEN IQ ADJUSTABLE CUFF
|
Facility
|
IP
|
$1,523.00
|
|
| Hospital Charge Code |
10526812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,294.55 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
|
|
ACUMEN IQ SENSOR 84/213CM
|
Facility
|
OP
|
$1,523.00
|
|
| Hospital Charge Code |
10526814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$761.50 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: AlohaCare Medicaid |
$761.50
|
| Rate for Payer: AlohaCare Medicare |
$761.50
|
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Devoted Health Medicare |
$837.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$761.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,446.85
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Humana Medicare |
$761.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$776.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$761.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$761.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$761.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$761.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,110.11
|
|
|
ACUMEN IQ SENSOR 84/213CM
|
Facility
|
IP
|
$1,523.00
|
|
| Hospital Charge Code |
10526814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,294.55 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
|
|
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION
|
Facility
|
IP
|
$12,544.03
|
|
|
Service Code
|
MSDRG 880
|
| Min. Negotiated Rate |
$12,544.03 |
| Max. Negotiated Rate |
$12,544.03 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,544.03
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC
|
Facility
|
IP
|
$51,629.40
|
|
|
Service Code
|
MSDRG 289
|
| Min. Negotiated Rate |
$51,629.40 |
| Max. Negotiated Rate |
$51,629.40 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,629.40
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC
|
Facility
|
IP
|
$51,629.40
|
|
|
Service Code
|
MSDRG 288
|
| Min. Negotiated Rate |
$51,629.40 |
| Max. Negotiated Rate |
$51,629.40 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,629.40
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$51,629.40
|
|
|
Service Code
|
MSDRG 290
|
| Min. Negotiated Rate |
$51,629.40 |
| Max. Negotiated Rate |
$51,629.40 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,629.40
|
|
|
Acute Hepatitis Panel FSI
|
Facility
|
OP
|
$587.00
|
|
|
Service Code
|
HCPCS 80074
|
| Hospital Charge Code |
8117762
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$569.39 |
| Rate for Payer: AlohaCare Medicaid |
$293.50
|
| Rate for Payer: AlohaCare Medicare |
$293.50
|
| Rate for Payer: Cash Price |
$381.55
|
| Rate for Payer: Cash Price |
$381.55
|
| Rate for Payer: Devoted Health Medicare |
$322.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$65.82
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$293.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$69.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.63
|
| Rate for Payer: Health Management Network Commercial |
$498.95
|
| Rate for Payer: Humana Medicare |
$293.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$528.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$299.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$293.50
|
| Rate for Payer: MDX Hawaii PPO |
$569.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$293.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$293.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$293.50
|
| Rate for Payer: University Health Alliance Commercial |
$123.10
|
|
|
Acute Hepatitis Panel FSI
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
HCPCS 80074
|
| Hospital Charge Code |
8117762
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$498.95 |
| Max. Negotiated Rate |
$569.39 |
| Rate for Payer: Cash Price |
$381.55
|
| Rate for Payer: Health Management Network Commercial |
$498.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$528.30
|
| Rate for Payer: MDX Hawaii PPO |
$569.39
|
|
|
ACUTE LEUKEMIA WITH CC
|
Facility
|
IP
|
$150,273.42
|
|
|
Service Code
|
MSDRG 835
|
| Min. Negotiated Rate |
$150,273.42 |
| Max. Negotiated Rate |
$150,273.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$150,273.42
|
|
|
ACUTE LEUKEMIA WITH MCC
|
Facility
|
IP
|
$150,273.42
|
|
|
Service Code
|
MSDRG 834
|
| Min. Negotiated Rate |
$150,273.42 |
| Max. Negotiated Rate |
$150,273.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$150,273.42
|
|
|
ACUTE LEUKEMIA WITH OTHER PROCEDURES
|
Facility
|
IP
|
$150,273.42
|
|
|
Service Code
|
MSDRG 850
|
| Min. Negotiated Rate |
$150,273.42 |
| Max. Negotiated Rate |
$150,273.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$150,273.42
|
|
|
ACUTE LEUKEMIA WITHOUT CC/MCC
|
Facility
|
IP
|
$150,273.42
|
|
|
Service Code
|
MSDRG 836
|
| Min. Negotiated Rate |
$150,273.42 |
| Max. Negotiated Rate |
$150,273.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$150,273.42
|
|
