|
NP SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG #4 TAB (WHR)
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: AlohaCare Medicaid |
$3.49
|
| Rate for Payer: AlohaCare Medicare |
$6.28
|
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Devoted Health Medicare |
$6.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.63
|
| Rate for Payer: Health Management Network Commercial |
$5.93
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.28
|
| Rate for Payer: MDX Hawaii PPO |
$6.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.28
|
| Rate for Payer: University Health Alliance Commercial |
$5.09
|
|
|
NP SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG #4 TAB (WHR)
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$6.77 |
| Rate for Payer: Cash Price |
$4.54
|
| Rate for Payer: Health Management Network Commercial |
$5.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.28
|
| Rate for Payer: MDX Hawaii PPO |
$6.77
|
|
|
NP TRAMADOL 50 MG #5 TAB (WHR)
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Health Management Network Commercial |
$4.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.35
|
| Rate for Payer: MDX Hawaii PPO |
$4.69
|
|
|
NP TRAMADOL 50 MG #5 TAB (WHR)
|
Facility
|
OP
|
$4.83
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: AlohaCare Medicaid |
$2.42
|
| Rate for Payer: AlohaCare Medicare |
$4.35
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Devoted Health Medicare |
$4.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.59
|
| Rate for Payer: Health Management Network Commercial |
$4.11
|
| Rate for Payer: Humana Medicare |
$4.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.35
|
| Rate for Payer: MDX Hawaii PPO |
$4.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.35
|
| Rate for Payer: University Health Alliance Commercial |
$3.52
|
|
|
NP ZOFRAN ODT 4 MG #4 TAB (WHR)
|
Facility
|
OP
|
$407.78
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.89 |
| Max. Negotiated Rate |
$403.70 |
| Rate for Payer: AlohaCare Medicaid |
$203.89
|
| Rate for Payer: AlohaCare Medicare |
$367.00
|
| Rate for Payer: Cash Price |
$265.06
|
| Rate for Payer: Devoted Health Medicare |
$403.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$367.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$387.39
|
| Rate for Payer: Health Management Network Commercial |
$346.61
|
| Rate for Payer: Humana Medicare |
$367.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$207.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$367.00
|
| Rate for Payer: MDX Hawaii PPO |
$395.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$367.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$367.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$367.00
|
| Rate for Payer: University Health Alliance Commercial |
$297.23
|
|
|
NP ZOFRAN ODT 4 MG #4 TAB (WHR)
|
Facility
|
IP
|
$407.78
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$346.61 |
| Max. Negotiated Rate |
$395.55 |
| Rate for Payer: Cash Price |
$265.06
|
| Rate for Payer: Health Management Network Commercial |
$346.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.00
|
| Rate for Payer: MDX Hawaii PPO |
$395.55
|
|
|
NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
OP
|
$43.46
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$43.03 |
| Rate for Payer: AlohaCare Medicaid |
$21.73
|
| Rate for Payer: AlohaCare Medicare |
$39.11
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Devoted Health Medicare |
$43.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.29
|
| Rate for Payer: Health Management Network Commercial |
$36.94
|
| Rate for Payer: Humana Medicare |
$39.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.11
|
| Rate for Payer: MDX Hawaii PPO |
$42.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.11
|
| Rate for Payer: University Health Alliance Commercial |
$31.68
|
|
|
NS 1000 ML WITH KCL 20 MEQ/L IV PREMIX
|
Facility
|
IP
|
$43.46
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.94 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: Health Management Network Commercial |
$36.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.11
|
| Rate for Payer: MDX Hawaii PPO |
$42.16
|
|
|
NYSTATIN 100000 UNIT/G TOP CR
|
Facility
|
IP
|
$126.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.68 |
| Max. Negotiated Rate |
$122.88 |
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Health Management Network Commercial |
$107.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.01
|
| Rate for Payer: MDX Hawaii PPO |
$122.88
|
|
|
NYSTATIN 100000 UNIT/G TOP CR
|
Facility
|
OP
|
$126.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.34 |
| Max. Negotiated Rate |
$125.41 |
| Rate for Payer: AlohaCare Medicaid |
$63.34
|
| Rate for Payer: AlohaCare Medicare |
$114.01
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Devoted Health Medicare |
$125.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.35
|
| Rate for Payer: Health Management Network Commercial |
$107.68
|
| Rate for Payer: Humana Medicare |
$114.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.01
|
| Rate for Payer: MDX Hawaii PPO |
$122.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.01
|
| Rate for Payer: University Health Alliance Commercial |
$92.34
|
|
|
NYSTATIN 100000 UNIT/G TOP POWD
|
Facility
|
IP
|
$178.72
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$151.91 |
| Max. Negotiated Rate |
$173.36 |
| Rate for Payer: Cash Price |
$116.17
|
| Rate for Payer: Cash Price |
$85.61
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Cash Price |
$280.13
|
| Rate for Payer: Health Management Network Commercial |
$111.95
|
| Rate for Payer: Health Management Network Commercial |
$151.91
|
| Rate for Payer: Health Management Network Commercial |
$366.32
|
| Rate for Payer: Health Management Network Commercial |
$83.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.47
|
| Rate for Payer: MDX Hawaii PPO |
$173.36
|
| Rate for Payer: MDX Hawaii PPO |
$418.04
|
| Rate for Payer: MDX Hawaii PPO |
$95.35
|
| Rate for Payer: MDX Hawaii PPO |
$127.76
|
|
|
NYSTATIN 100000 UNIT/G TOP POWD
|
Facility
|
OP
|
$98.30
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.15 |
| Max. Negotiated Rate |
$97.32 |
| Rate for Payer: Kaiser Permanente Commercial |
$88.47
|
| Rate for Payer: AlohaCare Medicaid |
$49.15
|
| Rate for Payer: AlohaCare Medicaid |
$215.49
|
| Rate for Payer: AlohaCare Medicaid |
$65.86
|
| Rate for Payer: AlohaCare Medicaid |
$89.36
|
| Rate for Payer: AlohaCare Medicare |
$160.85
|
| Rate for Payer: AlohaCare Medicare |
$118.54
|
| Rate for Payer: AlohaCare Medicare |
$88.47
|
| Rate for Payer: AlohaCare Medicare |
$387.87
|
| Rate for Payer: Cash Price |
$85.61
|
| Rate for Payer: Cash Price |
$280.13
|
| Rate for Payer: Cash Price |
$116.17
|
| Rate for Payer: Cash Price |
$63.90
|
| Rate for Payer: Devoted Health Medicare |
$176.93
|
| Rate for Payer: Devoted Health Medicare |
$97.32
|
| Rate for Payer: Devoted Health Medicare |
$130.39
|
| Rate for Payer: Devoted Health Medicare |
$426.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$387.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$409.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$169.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.39
|
| Rate for Payer: Health Management Network Commercial |
$151.91
|
| Rate for Payer: Health Management Network Commercial |
$111.95
|
| Rate for Payer: Health Management Network Commercial |
$366.32
|
| Rate for Payer: Health Management Network Commercial |
$83.56
|
| Rate for Payer: Humana Medicare |
$387.87
|
| Rate for Payer: Humana Medicare |
$160.85
|
| Rate for Payer: Humana Medicare |
$118.54
|
| Rate for Payer: Humana Medicare |
$88.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$160.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$219.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$387.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.47
|
| Rate for Payer: MDX Hawaii PPO |
$173.36
|
| Rate for Payer: MDX Hawaii PPO |
$418.04
|
| Rate for Payer: MDX Hawaii PPO |
$95.35
|
| Rate for Payer: MDX Hawaii PPO |
$127.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$387.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$387.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$387.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.54
|
| Rate for Payer: University Health Alliance Commercial |
$314.13
|
| Rate for Payer: University Health Alliance Commercial |
$130.27
|
| Rate for Payer: University Health Alliance Commercial |
$71.65
|
| Rate for Payer: University Health Alliance Commercial |
$96.00
|
|
|
NYSTATIN 100000 UNIT/ML PO SUSP
|
Facility
|
IP
|
$12.98
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$12.59 |
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Health Management Network Commercial |
$11.03
|
| Rate for Payer: Health Management Network Commercial |
$10.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.26
|
| Rate for Payer: MDX Hawaii PPO |
$12.13
|
| Rate for Payer: MDX Hawaii PPO |
$12.59
|
|
|
NYSTATIN 100000 UNIT/ML PO SUSP
|
Facility
|
OP
|
$12.51
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: AlohaCare Medicaid |
$6.25
|
| Rate for Payer: AlohaCare Medicaid |
$6.49
|
| Rate for Payer: AlohaCare Medicare |
$11.26
|
| Rate for Payer: AlohaCare Medicare |
$11.68
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Devoted Health Medicare |
$12.38
|
| Rate for Payer: Devoted Health Medicare |
$12.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.88
|
| Rate for Payer: Health Management Network Commercial |
$10.63
|
| Rate for Payer: Health Management Network Commercial |
$11.03
|
| Rate for Payer: Humana Medicare |
$11.68
|
| Rate for Payer: Humana Medicare |
$11.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.26
|
| Rate for Payer: MDX Hawaii PPO |
$12.59
|
| Rate for Payer: MDX Hawaii PPO |
$12.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.68
|
| Rate for Payer: University Health Alliance Commercial |
$9.46
|
| Rate for Payer: University Health Alliance Commercial |
$9.12
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TOP OINT
|
Facility
|
IP
|
$358.39
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$304.63 |
| Max. Negotiated Rate |
$347.64 |
| Rate for Payer: Cash Price |
$232.95
|
| Rate for Payer: Health Management Network Commercial |
$304.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$322.55
|
| Rate for Payer: MDX Hawaii PPO |
$347.64
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TOP OINT
|
Facility
|
OP
|
$358.39
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.19 |
| Max. Negotiated Rate |
$354.81 |
| Rate for Payer: AlohaCare Medicaid |
$179.19
|
| Rate for Payer: AlohaCare Medicare |
$322.55
|
| Rate for Payer: Cash Price |
$232.95
|
| Rate for Payer: Devoted Health Medicare |
$354.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$322.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$340.47
|
| Rate for Payer: Health Management Network Commercial |
$304.63
|
| Rate for Payer: Humana Medicare |
$322.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$322.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$182.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$322.55
|
| Rate for Payer: MDX Hawaii PPO |
$347.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$322.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$322.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$322.55
|
| Rate for Payer: University Health Alliance Commercial |
$261.23
|
|
|
OBSERVATION
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
H0000044
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicare |
$175.50
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Devoted Health Medicare |
$193.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Humana Medicare |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.50
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
|
|
OBSERVATION
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
H0000044
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
|
|
OBSERVATION
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
H0000043
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicare |
$175.50
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Devoted Health Medicare |
$193.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Humana Medicare |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.50
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
|
|
OBSERVATION
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
H0000043
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
|
|
OBSERVATION CARVE OUT
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
K0000101
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
|
|
OBSERVATION CARVE OUT
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS 99221
|
| Hospital Charge Code |
K0000101
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$53.33 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicare |
$175.50
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Cash Price |
$126.75
|
| Rate for Payer: Devoted Health Medicare |
$193.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Humana Medicare |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.50
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.50
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
|
|
OCCULT BLOOD,STOOL
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
H3011429
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$221.76 |
| Rate for Payer: AlohaCare Medicaid |
$112.00
|
| Rate for Payer: AlohaCare Medicare |
$201.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Devoted Health Medicare |
$221.76
|
| 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 |
$201.60
|
| 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 |
$190.40
|
| Rate for Payer: Humana Medicare |
$201.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$201.60
|
| Rate for Payer: MDX Hawaii PPO |
$217.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$201.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$201.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$201.60
|
| Rate for Payer: University Health Alliance Commercial |
$41.11
|
|
|
OCCULT BLOOD,STOOL
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
H3011429
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$190.40 |
| Max. Negotiated Rate |
$217.28 |
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.60
|
| Rate for Payer: MDX Hawaii PPO |
$217.28
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN
|
Facility
|
IP
|
$21.53
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$20.88 |
| Rate for Payer: Cash Price |
$13.99
|
| Rate for Payer: Health Management Network Commercial |
$18.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.38
|
| Rate for Payer: MDX Hawaii PPO |
$20.88
|
|
