|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$57,951.39
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$57,951.39 |
| Max. Negotiated Rate |
$57,951.39 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$57,951.39
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$60,795.63
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$60,795.63 |
| Max. Negotiated Rate |
$60,795.63 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60,795.63
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$29,983.03
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$29,983.03 |
| Max. Negotiated Rate |
$29,983.03 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29,983.03
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$59,894.95
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$59,894.95 |
| Max. Negotiated Rate |
$59,894.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59,894.95
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$59,894.95
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$59,894.95 |
| Max. Negotiated Rate |
$59,894.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59,894.95
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$14,150.09
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$14,150.09 |
| Max. Negotiated Rate |
$14,150.09 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,150.09
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$57,738.07
|
|
|
Service Code
|
MSDRG 574
|
| Min. Negotiated Rate |
$57,738.07 |
| Max. Negotiated Rate |
$57,738.07 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$57,738.07
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$60,890.44
|
|
|
Service Code
|
MSDRG 573
|
| Min. Negotiated Rate |
$60,890.44 |
| Max. Negotiated Rate |
$60,890.44 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60,890.44
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$34,984.15
|
|
|
Service Code
|
MSDRG 575
|
| Min. Negotiated Rate |
$34,984.15 |
| Max. Negotiated Rate |
$34,984.15 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34,984.15
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$46,076.69
|
|
|
Service Code
|
MSDRG 623
|
| Min. Negotiated Rate |
$46,076.69 |
| Max. Negotiated Rate |
$46,076.69 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,076.69
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$46,076.69
|
|
|
Service Code
|
MSDRG 622
|
| Min. Negotiated Rate |
$46,076.69 |
| Max. Negotiated Rate |
$46,076.69 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,076.69
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$46,076.69
|
|
|
Service Code
|
MSDRG 624
|
| Min. Negotiated Rate |
$46,076.69 |
| Max. Negotiated Rate |
$46,076.69 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,076.69
|
|
|
SKIN GRAFTS FOR INJURIES WITH CC/MCC
|
Facility
|
IP
|
$65,061.99
|
|
|
Service Code
|
MSDRG 904
|
| Min. Negotiated Rate |
$65,061.99 |
| Max. Negotiated Rate |
$65,061.99 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$65,061.99
|
|
|
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$65,061.99
|
|
|
Service Code
|
MSDRG 905
|
| Min. Negotiated Rate |
$65,061.99 |
| Max. Negotiated Rate |
$65,061.99 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$65,061.99
|
|
|
SKIN ULCERS WITH CC
|
Facility
|
IP
|
$23,038.34
|
|
|
Service Code
|
MSDRG 593
|
| Min. Negotiated Rate |
$23,038.34 |
| Max. Negotiated Rate |
$23,038.34 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,038.34
|
|
|
SKIN ULCERS WITH MCC
|
Facility
|
IP
|
$23,038.34
|
|
|
Service Code
|
MSDRG 592
|
| Min. Negotiated Rate |
$23,038.34 |
| Max. Negotiated Rate |
$23,038.34 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,038.34
|
|
|
SKIN ULCERS WITHOUT CC/MCC
|
Facility
|
IP
|
$23,038.34
|
|
|
Service Code
|
MSDRG 594
|
| Min. Negotiated Rate |
$23,038.34 |
| Max. Negotiated Rate |
$23,038.34 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,038.34
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$115.42
|
|
|
Service Code
|
NDC 63323008305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$111.96 |
| Rate for Payer: Cash Price |
$75.02
|
| Rate for Payer: Health Management Network Commercial |
$98.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.88
|
| Rate for Payer: MDX Hawaii PPO |
$111.96
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$45.39
|
|
|
Service Code
|
NDC 51754501201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$44.03 |
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$45.39
|
|
|
Service Code
|
NDC 51754501201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.70 |
| Max. Negotiated Rate |
$44.94 |
| Rate for Payer: AlohaCare Medicaid |
$22.70
|
| Rate for Payer: AlohaCare Medicare |
$40.85
|
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Devoted Health Medicare |
$44.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.12
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: Humana Medicare |
$40.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.85
|
| Rate for Payer: University Health Alliance Commercial |
$33.08
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$45.39
|
|
|
Service Code
|
NDC 51754501204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$44.03 |
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$45.39
|
|
|
Service Code
|
NDC 51754501204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.70 |
| Max. Negotiated Rate |
$44.94 |
| Rate for Payer: AlohaCare Medicaid |
$22.70
|
| Rate for Payer: AlohaCare Medicare |
$40.85
|
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Devoted Health Medicare |
$44.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.12
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: Humana Medicare |
$40.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.85
|
| Rate for Payer: University Health Alliance Commercial |
$33.08
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$115.42
|
|
|
Service Code
|
NDC 63323008303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$111.96 |
| Rate for Payer: Cash Price |
$75.02
|
| Rate for Payer: Health Management Network Commercial |
$98.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.88
|
| Rate for Payer: MDX Hawaii PPO |
$111.96
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$115.42
|
|
|
Service Code
|
NDC 63323008305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.71 |
| Max. Negotiated Rate |
$114.27 |
| Rate for Payer: AlohaCare Medicaid |
$57.71
|
| Rate for Payer: AlohaCare Medicare |
$103.88
|
| Rate for Payer: Cash Price |
$75.02
|
| Rate for Payer: Devoted Health Medicare |
$114.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$98.11
|
| Rate for Payer: Humana Medicare |
$103.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.88
|
| Rate for Payer: MDX Hawaii PPO |
$111.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.88
|
| Rate for Payer: University Health Alliance Commercial |
$84.13
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$115.42
|
|
|
Service Code
|
NDC 63323008303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.71 |
| Max. Negotiated Rate |
$114.27 |
| Rate for Payer: AlohaCare Medicaid |
$57.71
|
| Rate for Payer: AlohaCare Medicare |
$103.88
|
| Rate for Payer: Cash Price |
$75.02
|
| Rate for Payer: Devoted Health Medicare |
$114.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$98.11
|
| Rate for Payer: Humana Medicare |
$103.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.88
|
| Rate for Payer: MDX Hawaii PPO |
$111.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.88
|
| Rate for Payer: University Health Alliance Commercial |
$84.13
|
|
