|
FOSPHENYTOIN LOADING DOSE
|
Facility
|
IP
|
$491.82
|
|
|
Service Code
|
NDC 00069600121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$418.05 |
| Max. Negotiated Rate |
$477.07 |
| Rate for Payer: Cash Price |
$319.68
|
| Rate for Payer: Health Management Network Commercial |
$418.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$442.64
|
| Rate for Payer: MDX Hawaii PPO |
$477.07
|
|
|
FOSPHENYTOIN LOADING DOSE
|
Facility
|
OP
|
$491.82
|
|
|
Service Code
|
NDC 00069600121
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.91 |
| Max. Negotiated Rate |
$486.90 |
| Rate for Payer: AlohaCare Medicaid |
$245.91
|
| Rate for Payer: AlohaCare Medicare |
$442.64
|
| Rate for Payer: Cash Price |
$319.68
|
| Rate for Payer: Devoted Health Medicare |
$486.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$442.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$467.23
|
| Rate for Payer: Health Management Network Commercial |
$418.05
|
| Rate for Payer: Humana Medicare |
$442.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$442.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$250.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$442.64
|
| Rate for Payer: MDX Hawaii PPO |
$477.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$442.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$442.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$295.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$442.64
|
| Rate for Payer: University Health Alliance Commercial |
$358.49
|
|
|
FOSPHENYTOIN MAINTENANCE DOSE
|
Facility
|
OP
|
$185.39
|
|
|
Service Code
|
NDC 00069600125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.69 |
| Max. Negotiated Rate |
$183.54 |
| Rate for Payer: AlohaCare Medicaid |
$92.69
|
| Rate for Payer: AlohaCare Medicare |
$166.85
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Devoted Health Medicare |
$183.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$166.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$176.12
|
| Rate for Payer: Health Management Network Commercial |
$157.58
|
| Rate for Payer: Humana Medicare |
$166.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$166.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$94.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$166.85
|
| Rate for Payer: MDX Hawaii PPO |
$179.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$166.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$166.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$111.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$166.85
|
| Rate for Payer: University Health Alliance Commercial |
$135.13
|
|
|
FOSPHENYTOIN MAINTENANCE DOSE
|
Facility
|
IP
|
$185.39
|
|
|
Service Code
|
NDC 00069600125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$157.58 |
| Max. Negotiated Rate |
$179.83 |
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Health Management Network Commercial |
$157.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$166.85
|
| Rate for Payer: MDX Hawaii PPO |
$179.83
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$12,182.83
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$12,182.83 |
| Max. Negotiated Rate |
$12,182.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,182.83
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$12,182.83
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$12,182.83 |
| Max. Negotiated Rate |
$12,182.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,182.83
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$17,444.67
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$17,444.67 |
| Max. Negotiated Rate |
$17,444.67 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17,444.67
|
|
|
FRACTURES OF HIP AND PELVIS WITHOUT MCC
|
Facility
|
IP
|
$17,444.67
|
|
|
Service Code
|
MSDRG 536
|
| Min. Negotiated Rate |
$17,444.67 |
| Max. Negotiated Rate |
$17,444.67 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17,444.67
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC
|
Facility
|
IP
|
$13,154.61
|
|
|
Service Code
|
MSDRG 562
|
| Min. Negotiated Rate |
$13,154.61 |
| Max. Negotiated Rate |
$13,154.61 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,154.61
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC
|
Facility
|
IP
|
$13,154.61
|
|
|
Service Code
|
MSDRG 563
|
| Min. Negotiated Rate |
$13,154.61 |
| Max. Negotiated Rate |
$13,154.61 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,154.61
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$18,985.30
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$18,985.30 |
| Max. Negotiated Rate |
$18,985.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18,985.30
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
HCPCS J1938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: AlohaCare Medicaid |
$2.76
|
| Rate for Payer: AlohaCare Medicaid |
$8.10
|
| Rate for Payer: AlohaCare Medicaid |
$11.54
|
| Rate for Payer: AlohaCare Medicaid |
$16.12
|
| Rate for Payer: AlohaCare Medicare |
$14.57
|
| Rate for Payer: AlohaCare Medicare |
$20.78
|
| Rate for Payer: AlohaCare Medicare |
$29.02
|
| Rate for Payer: AlohaCare Medicare |
$4.97
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$15.01
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$15.01
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Devoted Health Medicare |
$5.46
|
| Rate for Payer: Devoted Health Medicare |
$16.03
|
| Rate for Payer: Devoted Health Medicare |
$22.86
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.38
|
| Rate for Payer: Health Management Network Commercial |
$4.69
|
| Rate for Payer: Health Management Network Commercial |
$19.63
|
| Rate for Payer: Health Management Network Commercial |
$13.76
|
| Rate for Payer: Health Management Network Commercial |
$27.40
|
| Rate for Payer: Humana Medicare |
$29.02
|
| Rate for Payer: Humana Medicare |
$4.97
|
| Rate for Payer: Humana Medicare |
$20.78
|
| Rate for Payer: Humana Medicare |
$14.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.78
|
| Rate for Payer: MDX Hawaii PPO |
$15.70
|
| Rate for Payer: MDX Hawaii PPO |
$22.40
|
| Rate for Payer: MDX Hawaii PPO |
$31.27
|
| Rate for Payer: MDX Hawaii PPO |
$5.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.97
|
| Rate for Payer: University Health Alliance Commercial |
$16.83
|
| Rate for Payer: University Health Alliance Commercial |
$11.80
|
| Rate for Payer: University Health Alliance Commercial |
$23.50
|
| Rate for Payer: University Health Alliance Commercial |
$4.02
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$23.09
|
|
|
Service Code
|
HCPCS J1938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.63 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Cash Price |
$15.01
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Health Management Network Commercial |
$19.63
|
| Rate for Payer: Health Management Network Commercial |
$27.40
|
| Rate for Payer: Health Management Network Commercial |
$13.76
|
| Rate for Payer: Health Management Network Commercial |
$4.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.57
|
| Rate for Payer: MDX Hawaii PPO |
$5.35
|
| Rate for Payer: MDX Hawaii PPO |
$22.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.70
|
| Rate for Payer: MDX Hawaii PPO |
$31.27
|
|
|
FUROSEMIDE 20 MG PO TABLET
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$2.42
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: MDX Hawaii PPO |
$2.76
|
|
|
FUROSEMIDE 20 MG PO TABLET
|
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 Medicaid |
$1.43
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: AlohaCare Medicare |
$2.56
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Devoted Health Medicare |
$2.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Health Management Network Commercial |
$2.42
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$2.76
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.56
|
| Rate for Payer: University Health Alliance Commercial |
$2.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
FUROSEMIDE 40 MG PO TABLET
|
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
|
|
|
FUROSEMIDE 40 MG PO TABLET
|
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
|
|
|
GABAPENTIN 100 MG PO CAP
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: AlohaCare Medicaid |
$1.61
|
| Rate for Payer: AlohaCare Medicaid |
$1.49
|
| Rate for Payer: AlohaCare Medicare |
$2.67
|
| Rate for Payer: AlohaCare Medicare |
$2.91
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Devoted Health Medicare |
$3.20
|
| Rate for Payer: Devoted Health Medicare |
$2.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Health Management Network Commercial |
$2.52
|
| Rate for Payer: Humana Medicare |
$2.91
|
| Rate for Payer: Humana Medicare |
$2.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$2.88
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.67
|
| Rate for Payer: University Health Alliance Commercial |
$2.35
|
| Rate for Payer: University Health Alliance Commercial |
$2.16
|
|
|
GABAPENTIN 100 MG PO CAP
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Health Management Network Commercial |
$2.52
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
| Rate for Payer: MDX Hawaii PPO |
$2.88
|
|
|
GABAPENTIN 300 MG PO CAP
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$7.38 |
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Health Management Network Commercial |
$6.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.85
|
| Rate for Payer: MDX Hawaii PPO |
$7.38
|
|
|
GABAPENTIN 300 MG PO CAP
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$7.53 |
| Rate for Payer: AlohaCare Medicaid |
$3.81
|
| Rate for Payer: AlohaCare Medicare |
$6.85
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Devoted Health Medicare |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.23
|
| Rate for Payer: Health Management Network Commercial |
$6.47
|
| Rate for Payer: Humana Medicare |
$6.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.85
|
| Rate for Payer: MDX Hawaii PPO |
$7.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.85
|
| Rate for Payer: University Health Alliance Commercial |
$5.55
|
|
|
GABAPENTIN 600 MG PO TABLET
|
Facility
|
IP
|
$13.37
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Health Management Network Commercial |
$11.36
|
| Rate for Payer: Health Management Network Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.75
|
| Rate for Payer: MDX Hawaii PPO |
$1.88
|
| Rate for Payer: MDX Hawaii PPO |
$12.97
|
|
|
GABAPENTIN 600 MG PO TABLET
|
Facility
|
OP
|
$1.94
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: AlohaCare Medicaid |
$0.97
|
| Rate for Payer: AlohaCare Medicaid |
$6.68
|
| Rate for Payer: AlohaCare Medicare |
$12.03
|
| Rate for Payer: AlohaCare Medicare |
$1.75
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Devoted Health Medicare |
$1.92
|
| Rate for Payer: Devoted Health Medicare |
$13.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network Commercial |
$1.65
|
| Rate for Payer: Health Management Network Commercial |
$11.36
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: Humana Medicare |
$12.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.75
|
| Rate for Payer: MDX Hawaii PPO |
$12.97
|
| Rate for Payer: MDX Hawaii PPO |
$1.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.03
|
| Rate for Payer: University Health Alliance Commercial |
$1.41
|
| Rate for Payer: University Health Alliance Commercial |
$9.75
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$21,355.50
|
|
|
Service Code
|
MSDRG 378
|
| Min. Negotiated Rate |
$21,355.50 |
| Max. Negotiated Rate |
$21,355.50 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,355.50
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$21,355.50
|
|
|
Service Code
|
MSDRG 377
|
| Min. Negotiated Rate |
$21,355.50 |
| Max. Negotiated Rate |
$21,355.50 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,355.50
|
|
