|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$2,726.15
|
|
|
Service Code
|
APR-DRG 2801
|
| Min. Negotiated Rate |
$2,726.15 |
| Max. Negotiated Rate |
$2,726.15 |
| Rate for Payer: AlohaCare Medicaid |
$2,726.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,726.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,726.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,726.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,726.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,726.15
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$3,389.70
|
|
|
Service Code
|
APR-DRG 2802
|
| Min. Negotiated Rate |
$3,389.70 |
| Max. Negotiated Rate |
$3,389.70 |
| Rate for Payer: AlohaCare Medicaid |
$3,389.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,389.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,389.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,389.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,389.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,389.70
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$5,002.09
|
|
|
Service Code
|
APR-DRG 2803
|
| Min. Negotiated Rate |
$5,002.09 |
| Max. Negotiated Rate |
$5,002.09 |
| Rate for Payer: AlohaCare Medicaid |
$5,002.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5,002.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5,002.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,002.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,002.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,002.09
|
|
|
ALCOHOLIC LIVER DISEASE
|
Facility
|
IP
|
$10,159.56
|
|
|
Service Code
|
APR-DRG 2804
|
| Min. Negotiated Rate |
$10,159.56 |
| Max. Negotiated Rate |
$10,159.56 |
| Rate for Payer: AlohaCare Medicaid |
$10,159.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10,159.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10,159.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,159.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,159.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,159.56
|
|
|
ALENDRONATE 70 MG PO TABLET
|
Facility
|
OP
|
$102.83
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.44 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Cash Price |
$66.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.69
|
| Rate for Payer: Health Management Network Commercial |
$87.38
|
| Rate for Payer: Health Management Network Commercial |
$87.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.43
|
| Rate for Payer: MDX Hawaii PPO |
$99.72
|
| Rate for Payer: MDX Hawaii PPO |
$99.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.70
|
| Rate for Payer: University Health Alliance Commercial |
$74.95
|
| Rate for Payer: University Health Alliance Commercial |
$74.93
|
|
|
ALENDRONATE 70 MG PO TABLET
|
Facility
|
IP
|
$102.80
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.38 |
| Max. Negotiated Rate |
$99.72 |
| Rate for Payer: Cash Price |
$66.82
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Health Management Network Commercial |
$87.38
|
| Rate for Payer: Health Management Network Commercial |
$87.41
|
| Rate for Payer: MDX Hawaii PPO |
$99.72
|
| Rate for Payer: MDX Hawaii PPO |
$99.75
|
|
|
Alexis O C-Section Protector-Retractor Xlrg [3643831]
|
Facility
|
OP
|
$716.05
|
|
| Hospital Charge Code |
3643831
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$365.19 |
| Max. Negotiated Rate |
$694.57 |
| Rate for Payer: Cash Price |
$465.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$680.25
|
| Rate for Payer: Health Management Network Commercial |
$608.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$451.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$365.19
|
| Rate for Payer: MDX Hawaii PPO |
$694.57
|
| Rate for Payer: University Health Alliance Commercial |
$521.93
|
|
|
Alexis O C-Section Protector-Retractor Xlrg [3643831]
|
Facility
|
IP
|
$716.05
|
|
| Hospital Charge Code |
3643831
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$608.64 |
| Max. Negotiated Rate |
$694.57 |
| Rate for Payer: Cash Price |
$465.43
|
| Rate for Payer: Health Management Network Commercial |
$608.64
|
| Rate for Payer: MDX Hawaii PPO |
$694.57
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$2,456.79
|
|
|
Service Code
|
APR-DRG 8112
|
| Min. Negotiated Rate |
$2,456.79 |
| Max. Negotiated Rate |
$2,456.79 |
| Rate for Payer: AlohaCare Medicaid |
$2,456.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,456.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,456.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,456.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,456.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,456.79
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$1,679.25
|
|
|
Service Code
|
APR-DRG 8111
|
| Min. Negotiated Rate |
$1,679.25 |
| Max. Negotiated Rate |
$1,679.25 |
| Rate for Payer: AlohaCare Medicaid |
$1,679.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,679.25
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,679.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,679.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,679.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,679.25
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$4,650.57
|
|
|
Service Code
|
APR-DRG 8113
|
| Min. Negotiated Rate |
$4,650.57 |
| Max. Negotiated Rate |
$4,650.57 |
| Rate for Payer: AlohaCare Medicaid |
$4,650.57
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,650.57
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,650.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,650.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,650.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,650.57
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$9,322.16
|
|
|
Service Code
|
APR-DRG 8114
|
| Min. Negotiated Rate |
$9,322.16 |
| Max. Negotiated Rate |
$9,322.16 |
| Rate for Payer: AlohaCare Medicaid |
$9,322.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9,322.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9,322.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,322.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,322.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,322.16
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
|
IP
|
$29,007.60
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$13,355.28 |
| Max. Negotiated Rate |
$29,007.60 |
| Rate for Payer: AlohaCare Medicare |
$22,117.69
|
| Rate for Payer: Devoted Health Medicare |
$24,329.46
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,355.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22,117.69
|
| Rate for Payer: Humana Medicare |
$22,117.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$29,007.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$22,117.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$22,117.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$22,117.69
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
|
IP
|
$13,355.28
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$8,763.69 |
| Max. Negotiated Rate |
$13,355.28 |
| Rate for Payer: AlohaCare Medicare |
$8,763.69
|
| Rate for Payer: Devoted Health Medicare |
$9,640.06
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,355.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,763.69
|
| Rate for Payer: Humana Medicare |
$8,763.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,493.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,763.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,763.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,763.69
|
|
|
Alloderm Select Con Lg Perf-Med .2-2.0 [3643585]
|
Facility
|
IP
|
$17,880.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
3643585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,012.80 |
| Max. Negotiated Rate |
$17,343.60 |
| Rate for Payer: Cash Price |
$11,622.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,516.00
|
| Rate for Payer: Health Management Network Commercial |
$15,198.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,343.60
|
| Rate for Payer: University Health Alliance Commercial |
$10,012.80
|
|
|
Alloderm Select Con Lg Perf-Med .2-2.0 [3643585]
|
Facility
|
OP
|
$17,880.00
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
3643585
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.01 |
| Max. Negotiated Rate |
$17,343.60 |
| Rate for Payer: AlohaCare Medicaid |
$147.01
|
| Rate for Payer: AlohaCare Medicare |
$147.01
|
| Rate for Payer: Cash Price |
$11,622.00
|
| Rate for Payer: Cash Price |
$11,622.00
|
| Rate for Payer: Devoted Health Medicare |
$161.71
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$183.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,516.00
|
| Rate for Payer: Health Management Network Commercial |
$15,198.00
|
| Rate for Payer: Humana Medicare |
$147.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,264.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,118.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.01
|
| Rate for Payer: MDX Hawaii PPO |
$17,343.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$161.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.01
|
| Rate for Payer: University Health Alliance Commercial |
$10,012.80
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$41,268.02
|
|
|
Service Code
|
APR-DRG 0071
|
| Min. Negotiated Rate |
$41,268.02 |
| Max. Negotiated Rate |
$41,268.02 |
| Rate for Payer: AlohaCare Medicaid |
$41,268.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$41,268.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$41,268.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41,268.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41,268.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41,268.02
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$232,873.62
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$232,873.62 |
| Rate for Payer: AlohaCare Medicare |
$158,068.64
|
| Rate for Payer: Devoted Health Medicare |
$173,875.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$232,873.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158,068.64
|
| Rate for Payer: Humana Medicare |
$158,068.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$207,308.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$158,068.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$158,068.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$158,068.64
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$101,780.22
|
|
|
Service Code
|
APR-DRG 0074
|
| Min. Negotiated Rate |
$101,780.22 |
| Max. Negotiated Rate |
$101,780.22 |
| Rate for Payer: AlohaCare Medicaid |
$101,780.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$101,780.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$101,780.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101,780.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$101,780.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101,780.22
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$45,884.84
|
|
|
Service Code
|
APR-DRG 0072
|
| Min. Negotiated Rate |
$45,884.84 |
| Max. Negotiated Rate |
$45,884.84 |
| Rate for Payer: AlohaCare Medicaid |
$45,884.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$45,884.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$45,884.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45,884.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45,884.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45,884.84
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$66,463.13
|
|
|
Service Code
|
APR-DRG 0073
|
| Min. Negotiated Rate |
$66,463.13 |
| Max. Negotiated Rate |
$66,463.13 |
| Rate for Payer: AlohaCare Medicaid |
$66,463.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$66,463.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$66,463.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66,463.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66,463.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66,463.13
|
|
|
ALLOPURINOL 100 MG PO TABLET
|
Facility
|
OP
|
$2.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.74
|
| Rate for Payer: Health Management Network Commercial |
$1.56
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Health Management Network Commercial |
$2.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.41
|
| Rate for Payer: MDX Hawaii PPO |
$1.78
|
| Rate for Payer: MDX Hawaii PPO |
$2.03
|
| Rate for Payer: MDX Hawaii PPO |
$2.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.10
|
| Rate for Payer: University Health Alliance Commercial |
$2.01
|
| Rate for Payer: University Health Alliance Commercial |
$1.33
|
| Rate for Payer: University Health Alliance Commercial |
$1.52
|
|
|
ALLOPURINOL 100 MG PO TABLET
|
Facility
|
IP
|
$2.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Health Management Network Commercial |
$1.56
|
| Rate for Payer: Health Management Network Commercial |
$2.35
|
| Rate for Payer: MDX Hawaii PPO |
$1.78
|
| Rate for Payer: MDX Hawaii PPO |
$2.68
|
| Rate for Payer: MDX Hawaii PPO |
$2.03
|
|
|
ALLOPURINOL 300 MG PO TABLET
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network Commercial |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.61
|
| Rate for Payer: MDX Hawaii PPO |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.07
|
| Rate for Payer: University Health Alliance Commercial |
$3.72
|
|
|
ALLOPURINOL 300 MG PO TABLET
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Health Management Network Commercial |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$4.96
|
|
