|
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$311.72
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$302.37 |
| Rate for Payer: Cash Price |
$202.62
|
| Rate for Payer: Cash Price |
$251.19
|
| Rate for Payer: Health Management Network Commercial |
$328.48
|
| Rate for Payer: Health Management Network Commercial |
$264.96
|
| Rate for Payer: MDX Hawaii PPO |
$374.86
|
| Rate for Payer: MDX Hawaii PPO |
$302.37
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABLET
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.39
|
| Rate for Payer: Health Management Network Commercial |
$13.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.26
|
| Rate for Payer: MDX Hawaii PPO |
$15.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.72
|
| Rate for Payer: University Health Alliance Commercial |
$11.81
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABLET
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Health Management Network Commercial |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$15.71
|
|
|
AMPHOTERICIN B 50 MG INJ RECON.SOLN.
|
Facility
|
OP
|
$306.96
|
|
|
Service Code
|
HCPCS J0285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$297.75 |
| Rate for Payer: Cash Price |
$199.52
|
| Rate for Payer: Cash Price |
$199.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$34.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$34.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.61
|
| Rate for Payer: Health Management Network Commercial |
$260.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$156.55
|
| Rate for Payer: MDX Hawaii PPO |
$297.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$184.18
|
| Rate for Payer: University Health Alliance Commercial |
$223.74
|
|
|
AMPHOTERICIN B 50 MG INJ RECON.SOLN.
|
Facility
|
IP
|
$306.96
|
|
|
Service Code
|
HCPCS J0285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.92 |
| Max. Negotiated Rate |
$297.75 |
| Rate for Payer: Cash Price |
$199.52
|
| Rate for Payer: Health Management Network Commercial |
$260.92
|
| Rate for Payer: MDX Hawaii PPO |
$297.75
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR
|
Facility
|
OP
|
$874.62
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$848.38 |
| Rate for Payer: AlohaCare Medicaid |
$22.81
|
| Rate for Payer: AlohaCare Medicaid |
$22.81
|
| Rate for Payer: AlohaCare Medicare |
$22.81
|
| Rate for Payer: AlohaCare Medicare |
$22.81
|
| Rate for Payer: Cash Price |
$568.50
|
| Rate for Payer: Cash Price |
$585.53
|
| Rate for Payer: Cash Price |
$568.50
|
| Rate for Payer: Cash Price |
$585.53
|
| Rate for Payer: Devoted Health Medicare |
$25.09
|
| Rate for Payer: Devoted Health Medicare |
$25.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.81
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$830.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$855.78
|
| Rate for Payer: Health Management Network Commercial |
$765.70
|
| Rate for Payer: Health Management Network Commercial |
$743.43
|
| Rate for Payer: Humana Medicare |
$22.81
|
| Rate for Payer: Humana Medicare |
$22.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$446.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$459.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.81
|
| Rate for Payer: MDX Hawaii PPO |
$848.38
|
| Rate for Payer: MDX Hawaii PPO |
$873.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$524.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$540.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.81
|
| Rate for Payer: University Health Alliance Commercial |
$637.51
|
| Rate for Payer: University Health Alliance Commercial |
$656.61
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR
|
Facility
|
IP
|
$900.82
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$765.70 |
| Max. Negotiated Rate |
$873.80 |
| Rate for Payer: Cash Price |
$585.53
|
| Rate for Payer: Cash Price |
$568.50
|
| Rate for Payer: Health Management Network Commercial |
$743.43
|
| Rate for Payer: Health Management Network Commercial |
$765.70
|
| Rate for Payer: MDX Hawaii PPO |
$848.38
|
| Rate for Payer: MDX Hawaii PPO |
$873.80
|
|
|
AMPICILLIN SODIUM 1 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$51.36
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$49.82 |
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.79
|
| Rate for Payer: Health Management Network Commercial |
$43.66
|
| Rate for Payer: Health Management Network Commercial |
$41.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$47.80
|
| Rate for Payer: MDX Hawaii PPO |
$49.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.57
|
| Rate for Payer: University Health Alliance Commercial |
$37.44
|
| Rate for Payer: University Health Alliance Commercial |
$35.92
|
|
|
AMPICILLIN SODIUM 1 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$49.28
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.89 |
| Max. Negotiated Rate |
$47.80 |
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Health Management Network Commercial |
$41.89
|
| Rate for Payer: Health Management Network Commercial |
$43.66
|
| Rate for Payer: MDX Hawaii PPO |
$47.80
|
| Rate for Payer: MDX Hawaii PPO |
$49.82
|
|
|
AMPICILLIN SODIUM 2 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$87.36
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$84.74 |
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.02
|
| Rate for Payer: Health Management Network Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$43.24
|
| Rate for Payer: Health Management Network Commercial |
$70.91
|
| Rate for Payer: Health Management Network Commercial |
$74.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.94
|
| Rate for Payer: MDX Hawaii PPO |
$70.47
|
| Rate for Payer: MDX Hawaii PPO |
$49.34
|
| Rate for Payer: MDX Hawaii PPO |
$80.92
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$84.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.59
|
| Rate for Payer: University Health Alliance Commercial |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$52.95
|
| Rate for Payer: University Health Alliance Commercial |
$37.08
|
| Rate for Payer: University Health Alliance Commercial |
$33.43
|
| Rate for Payer: University Health Alliance Commercial |
$63.68
|
|
|
AMPICILLIN SODIUM 2 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$72.65
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$70.47 |
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Health Management Network Commercial |
$43.24
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$74.26
|
| Rate for Payer: Health Management Network Commercial |
$70.91
|
| Rate for Payer: MDX Hawaii PPO |
$49.34
|
| Rate for Payer: MDX Hawaii PPO |
$80.92
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$70.47
|
| Rate for Payer: MDX Hawaii PPO |
$84.74
|
|
|
AMPICILLIN SODIUM 500 MG INJ RECON.SOLN.
|
Facility
|
OP
|
$24.33
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.11
|
| Rate for Payer: Health Management Network Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.41
|
| Rate for Payer: MDX Hawaii PPO |
$23.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.60
|
| Rate for Payer: University Health Alliance Commercial |
$17.73
|
|
|
AMPICILLIN SODIUM 500 MG INJ RECON.SOLN.
|
Facility
|
IP
|
$24.33
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Health Management Network Commercial |
$20.68
|
| Rate for Payer: MDX Hawaii PPO |
$23.60
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$20.87
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.66
|
| Rate for Payer: Health Management Network Commercial |
$17.74
|
| Rate for Payer: Health Management Network Commercial |
$39.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.64
|
| Rate for Payer: MDX Hawaii PPO |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$20.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.21
|
| Rate for Payer: University Health Alliance Commercial |
$15.21
|
| Rate for Payer: University Health Alliance Commercial |
$34.27
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$47.01
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.96 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Health Management Network Commercial |
$17.74
|
| Rate for Payer: Health Management Network Commercial |
$39.96
|
| Rate for Payer: MDX Hawaii PPO |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$20.24
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$40.36
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.31 |
| Max. Negotiated Rate |
$39.15 |
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$26.23
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Health Management Network Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$41.75
|
| Rate for Payer: Health Management Network Commercial |
$34.31
|
| Rate for Payer: MDX Hawaii PPO |
$47.65
|
| Rate for Payer: MDX Hawaii PPO |
$39.15
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
| Rate for Payer: MDX Hawaii PPO |
$94.32
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$40.36
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$39.15 |
| Rate for Payer: Cash Price |
$26.23
|
| Rate for Payer: Cash Price |
$26.23
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.98
|
| Rate for Payer: Health Management Network Commercial |
$34.31
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Health Management Network Commercial |
$41.75
|
| Rate for Payer: Health Management Network Commercial |
$82.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.26
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
| Rate for Payer: MDX Hawaii PPO |
$47.65
|
| Rate for Payer: MDX Hawaii PPO |
$39.15
|
| Rate for Payer: MDX Hawaii PPO |
$94.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.25
|
| Rate for Payer: University Health Alliance Commercial |
$70.88
|
| Rate for Payer: University Health Alliance Commercial |
$16.09
|
| Rate for Payer: University Health Alliance Commercial |
$29.42
|
| Rate for Payer: University Health Alliance Commercial |
$35.80
|
|
|
AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)
|
Facility
|
OP
|
$10,679.55
|
|
|
Service Code
|
CPT 26952
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$10,679.55 |
| Rate for Payer: AlohaCare Medicaid |
$3,865.36
|
| Rate for Payer: AlohaCare Medicare |
$3,865.36
|
| Rate for Payer: Devoted Health Medicare |
$4,251.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9,416.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,865.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$849.21
|
| Rate for Payer: Humana Medicare |
$3,865.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,865.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,251.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,865.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,865.36
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
|
IP
|
$82,180.76
|
|
|
Service Code
|
MSDRG 240
|
| Min. Negotiated Rate |
$37,491.95 |
| Max. Negotiated Rate |
$82,180.76 |
| Rate for Payer: AlohaCare Medicare |
$37,491.95
|
| Rate for Payer: Devoted Health Medicare |
$41,241.14
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$82,180.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37,491.95
|
| Rate for Payer: Humana Medicare |
$37,491.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$49,171.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$37,491.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$37,491.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$37,491.95
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC
|
Facility
|
IP
|
$84,899.32
|
|
|
Service Code
|
MSDRG 239
|
| Min. Negotiated Rate |
$64,733.97 |
| Max. Negotiated Rate |
$84,899.32 |
| Rate for Payer: AlohaCare Medicare |
$64,733.97
|
| Rate for Payer: Devoted Health Medicare |
$71,207.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$82,180.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64,733.97
|
| Rate for Payer: Humana Medicare |
$64,733.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$84,899.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$64,733.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$64,733.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$64,733.97
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC
|
Facility
|
IP
|
$82,180.76
|
|
|
Service Code
|
MSDRG 241
|
| Min. Negotiated Rate |
$18,208.69 |
| Max. Negotiated Rate |
$82,180.76 |
| Rate for Payer: AlohaCare Medicare |
$18,208.69
|
| Rate for Payer: Devoted Health Medicare |
$20,029.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$82,180.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18,208.69
|
| Rate for Payer: Humana Medicare |
$18,208.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,880.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$18,208.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$18,208.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$18,208.69
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$41,391.72
|
|
|
Service Code
|
MSDRG 475
|
| Min. Negotiated Rate |
$29,931.75 |
| Max. Negotiated Rate |
$41,391.72 |
| Rate for Payer: AlohaCare Medicare |
$29,931.75
|
| Rate for Payer: Devoted Health Medicare |
$32,924.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,391.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29,931.75
|
| Rate for Payer: Humana Medicare |
$29,931.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$39,255.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$29,931.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$29,931.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$29,931.75
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$74,052.52
|
|
|
Service Code
|
MSDRG 474
|
| Min. Negotiated Rate |
$41,391.72 |
| Max. Negotiated Rate |
$74,052.52 |
| Rate for Payer: AlohaCare Medicare |
$56,463.51
|
| Rate for Payer: Devoted Health Medicare |
$62,109.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,391.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56,463.51
|
| Rate for Payer: Humana Medicare |
$56,463.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$74,052.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$56,463.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$56,463.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$56,463.51
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$41,391.72
|
|
|
Service Code
|
MSDRG 476
|
| Min. Negotiated Rate |
$15,522.89 |
| Max. Negotiated Rate |
$41,391.72 |
| Rate for Payer: AlohaCare Medicare |
$15,522.89
|
| Rate for Payer: Devoted Health Medicare |
$17,075.18
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,391.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15,522.89
|
| Rate for Payer: Humana Medicare |
$15,522.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,358.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$15,522.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$15,522.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$15,522.89
|
|
|
AMPUTATION, METATARSAL, WITH TOE, SINGLE
|
Facility
|
OP
|
$6,183.00
|
|
|
Service Code
|
CPT 28810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,183.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,865.36
|
| Rate for Payer: AlohaCare Medicare |
$3,865.36
|
| Rate for Payer: Devoted Health Medicare |
$4,251.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6,183.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,865.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Humana Medicare |
$3,865.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,865.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,251.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,865.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,865.36
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
