|
DILTIAZEM HCL 5 MG/ML IV SOLN
|
Facility
|
OP
|
$18.88
|
|
|
Service Code
|
HCPCS J1163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$18.69 |
| Rate for Payer: AlohaCare Medicaid |
$9.44
|
| Rate for Payer: AlohaCare Medicaid |
$19.86
|
| Rate for Payer: AlohaCare Medicaid |
$7.76
|
| Rate for Payer: AlohaCare Medicaid |
$26.80
|
| Rate for Payer: AlohaCare Medicare |
$48.25
|
| Rate for Payer: AlohaCare Medicare |
$13.97
|
| Rate for Payer: AlohaCare Medicare |
$16.99
|
| Rate for Payer: AlohaCare Medicare |
$35.76
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$12.27
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Cash Price |
$25.82
|
| Rate for Payer: Cash Price |
$12.27
|
| Rate for Payer: Cash Price |
$25.82
|
| Rate for Payer: Devoted Health Medicare |
$39.33
|
| Rate for Payer: Devoted Health Medicare |
$18.69
|
| Rate for Payer: Devoted Health Medicare |
$53.07
|
| Rate for Payer: Devoted Health Medicare |
$15.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.94
|
| Rate for Payer: Health Management Network Commercial |
$33.77
|
| Rate for Payer: Health Management Network Commercial |
$13.19
|
| Rate for Payer: Health Management Network Commercial |
$16.05
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Humana Medicare |
$13.97
|
| Rate for Payer: Humana Medicare |
$35.76
|
| Rate for Payer: Humana Medicare |
$16.99
|
| Rate for Payer: Humana Medicare |
$48.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.99
|
| Rate for Payer: MDX Hawaii PPO |
$38.54
|
| Rate for Payer: MDX Hawaii PPO |
$15.05
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$18.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.99
|
| Rate for Payer: University Health Alliance Commercial |
$11.31
|
| Rate for Payer: University Health Alliance Commercial |
$13.76
|
| Rate for Payer: University Health Alliance Commercial |
$28.96
|
| Rate for Payer: University Health Alliance Commercial |
$39.08
|
|
|
DILTIAZEM HCL 5 MG/ML IV SOLN
|
Facility
|
IP
|
$18.88
|
|
|
Service Code
|
HCPCS J1163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.05 |
| Max. Negotiated Rate |
$18.31 |
| Rate for Payer: Cash Price |
$12.27
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$25.82
|
| Rate for Payer: Cash Price |
$10.09
|
| Rate for Payer: Health Management Network Commercial |
$16.05
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Health Management Network Commercial |
$13.19
|
| Rate for Payer: Health Management Network Commercial |
$33.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.76
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$15.05
|
| Rate for Payer: MDX Hawaii PPO |
$18.31
|
| Rate for Payer: MDX Hawaii PPO |
$38.54
|
|
|
DIMETHYL SULFOXIDE (BULK) 99.99 % MISC LIQ
|
Facility
|
OP
|
$497.43
|
|
|
Service Code
|
HCPCS J1212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.72 |
| Max. Negotiated Rate |
$936.23 |
| Rate for Payer: AlohaCare Medicaid |
$248.72
|
| Rate for Payer: AlohaCare Medicare |
$447.69
|
| Rate for Payer: Cash Price |
$323.33
|
| Rate for Payer: Cash Price |
$323.33
|
| Rate for Payer: Devoted Health Medicare |
$492.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$742.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$936.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$447.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$742.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$472.56
|
| Rate for Payer: Health Management Network Commercial |
$422.82
|
| Rate for Payer: Humana Medicare |
$447.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$447.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$253.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$447.69
|
| Rate for Payer: MDX Hawaii PPO |
$482.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$447.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$447.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$298.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$447.69
|
| Rate for Payer: University Health Alliance Commercial |
$362.58
|
|
|
DIMETHYL SULFOXIDE (BULK) 99.99 % MISC LIQ
|
Facility
|
IP
|
$497.43
|
|
|
Service Code
|
HCPCS J1212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$422.82 |
| Max. Negotiated Rate |
$482.51 |
| Rate for Payer: Cash Price |
$323.33
|
| Rate for Payer: Health Management Network Commercial |
$422.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$447.69
|
| Rate for Payer: MDX Hawaii PPO |
$482.51
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML PO ELIX
|
Facility
|
OP
|
$28.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$28.47 |
| Rate for Payer: AlohaCare Medicaid |
$14.38
|
| Rate for Payer: AlohaCare Medicare |
$25.88
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Devoted Health Medicare |
$28.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.32
|
| Rate for Payer: Health Management Network Commercial |
$24.45
|
| Rate for Payer: Humana Medicare |
$25.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.88
|
| Rate for Payer: MDX Hawaii PPO |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.88
|
| Rate for Payer: University Health Alliance Commercial |
$20.96
|
|
|
DIPHENHYDRAMINE HCL 12.5 MG/5 ML PO ELIX
|
Facility
|
IP
|
$28.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.45 |
| Max. Negotiated Rate |
$27.90 |
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Health Management Network Commercial |
$24.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.88
|
| Rate for Payer: MDX Hawaii PPO |
$27.90
|
|
|
DIPHENHYDRAMINE HCL 25 MG PO CAP
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: AlohaCare Medicaid |
$0.60
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
DIPHENHYDRAMINE HCL 25 MG PO CAP
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$16.62
|
|
|
Service Code
|
HCPCS J1200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: AlohaCare Medicaid |
$8.31
|
| Rate for Payer: AlohaCare Medicaid |
$3.23
|
| Rate for Payer: AlohaCare Medicaid |
$5.30
|
| Rate for Payer: AlohaCare Medicare |
$5.82
|
| Rate for Payer: AlohaCare Medicare |
$9.54
|
| Rate for Payer: AlohaCare Medicare |
$14.96
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$6.41
|
| Rate for Payer: Devoted Health Medicare |
$16.45
|
| Rate for Payer: Devoted Health Medicare |
$10.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.54
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.79
|
| Rate for Payer: Health Management Network Commercial |
$9.01
|
| Rate for Payer: Health Management Network Commercial |
$14.13
|
| Rate for Payer: Health Management Network Commercial |
$5.50
|
| Rate for Payer: Humana Medicare |
$14.96
|
| Rate for Payer: Humana Medicare |
$9.54
|
| Rate for Payer: Humana Medicare |
$5.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$6.28
|
| Rate for Payer: MDX Hawaii PPO |
$10.28
|
| Rate for Payer: MDX Hawaii PPO |
$16.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.96
|
| Rate for Payer: University Health Alliance Commercial |
$4.72
|
| Rate for Payer: University Health Alliance Commercial |
$12.11
|
| Rate for Payer: University Health Alliance Commercial |
$7.73
|
|
|
DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$16.62
|
|
|
Service Code
|
HCPCS J1200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.13 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$6.89
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: Health Management Network Commercial |
$5.50
|
| Rate for Payer: Health Management Network Commercial |
$9.01
|
| Rate for Payer: Health Management Network Commercial |
$14.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.96
|
| Rate for Payer: MDX Hawaii PPO |
$16.12
|
| Rate for Payer: MDX Hawaii PPO |
$10.28
|
| Rate for Payer: MDX Hawaii PPO |
$6.28
|
|
|
DIPHENHYDRAMINE HCL 50 MG PO CAP
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: AlohaCare Medicaid |
$0.60
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
DIPHENHYDRAMINE HCL 50 MG PO CAP
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABLET
|
Facility
|
IP
|
$3.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.48
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
|
|
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABLET
|
Facility
|
OP
|
$3.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: AlohaCare Medicaid |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$3.48
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Devoted Health Medicare |
$3.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.68
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Humana Medicare |
$3.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.48
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.48
|
| Rate for Payer: University Health Alliance Commercial |
$2.82
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
OP
|
$134.50
|
|
|
Service Code
|
HCPCS 90700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$133.16 |
| Rate for Payer: AlohaCare Medicaid |
$67.25
|
| Rate for Payer: AlohaCare Medicaid |
$67.26
|
| Rate for Payer: AlohaCare Medicare |
$121.07
|
| Rate for Payer: AlohaCare Medicare |
$121.05
|
| Rate for Payer: Cash Price |
$87.44
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cash Price |
$87.44
|
| Rate for Payer: Devoted Health Medicare |
$133.16
|
| Rate for Payer: Devoted Health Medicare |
$133.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$32.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$32.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$32.42
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$32.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.79
|
| Rate for Payer: Health Management Network Commercial |
$114.34
|
| Rate for Payer: Health Management Network Commercial |
$114.33
|
| Rate for Payer: Humana Medicare |
$121.05
|
| Rate for Payer: Humana Medicare |
$121.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.07
|
| Rate for Payer: MDX Hawaii PPO |
$130.47
|
| Rate for Payer: MDX Hawaii PPO |
$130.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$80.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$80.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.07
|
| Rate for Payer: University Health Alliance Commercial |
$98.04
|
| Rate for Payer: University Health Alliance Commercial |
$98.05
|
|
|
DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP
|
Facility
|
IP
|
$134.50
|
|
|
Service Code
|
HCPCS 90700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.33 |
| Max. Negotiated Rate |
$130.47 |
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cash Price |
$87.44
|
| Rate for Payer: Health Management Network Commercial |
$114.33
|
| Rate for Payer: Health Management Network Commercial |
$114.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.07
|
| Rate for Payer: MDX Hawaii PPO |
$130.48
|
| Rate for Payer: MDX Hawaii PPO |
$130.47
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYR
|
Facility
|
OP
|
$212.38
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.63 |
| Max. Negotiated Rate |
$210.26 |
| Rate for Payer: AlohaCare Medicaid |
$106.19
|
| Rate for Payer: AlohaCare Medicare |
$191.14
|
| Rate for Payer: Cash Price |
$138.05
|
| Rate for Payer: Cash Price |
$138.05
|
| Rate for Payer: Devoted Health Medicare |
$210.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$38.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$191.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$38.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$201.76
|
| Rate for Payer: Health Management Network Commercial |
$180.52
|
| Rate for Payer: Humana Medicare |
$191.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$191.14
|
| Rate for Payer: MDX Hawaii PPO |
$206.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$191.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$191.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$127.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$191.14
|
| Rate for Payer: University Health Alliance Commercial |
$154.80
|
|
|
DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYR
|
Facility
|
IP
|
$212.38
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.52 |
| Max. Negotiated Rate |
$206.01 |
| Rate for Payer: Cash Price |
$138.05
|
| Rate for Payer: Health Management Network Commercial |
$180.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.14
|
| Rate for Payer: MDX Hawaii PPO |
$206.01
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$31,926.59
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$31,926.59 |
| Max. Negotiated Rate |
$31,926.59 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$31,926.59
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$31,926.59
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$31,926.59 |
| Max. Negotiated Rate |
$31,926.59 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$31,926.59
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$23,085.75
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$23,085.75 |
| Max. Negotiated Rate |
$23,085.75 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,085.75
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC
|
Facility
|
IP
|
$24,958.21
|
|
|
Service Code
|
MSDRG 439
|
| Min. Negotiated Rate |
$24,958.21 |
| Max. Negotiated Rate |
$24,958.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,958.21
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$24,958.21
|
|
|
Service Code
|
MSDRG 438
|
| Min. Negotiated Rate |
$24,958.21 |
| Max. Negotiated Rate |
$24,958.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,958.21
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$24,958.21
|
|
|
Service Code
|
MSDRG 440
|
| Min. Negotiated Rate |
$24,958.21 |
| Max. Negotiated Rate |
$24,958.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,958.21
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
|
IP
|
$21,118.48
|
|
|
Service Code
|
MSDRG 883
|
| Min. Negotiated Rate |
$21,118.48 |
| Max. Negotiated Rate |
$21,118.48 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,118.48
|
|
