|
Ijs-E Base Plate Assembly Ijs-Elb-Bpa [3643999]
|
Facility
|
IP
|
$22,408.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643999
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,548.76 |
| Max. Negotiated Rate |
$21,736.24 |
| Rate for Payer: Cash Price |
$14,565.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,685.95
|
| Rate for Payer: Health Management Network Commercial |
$19,047.22
|
| Rate for Payer: MDX Hawaii PPO |
$21,736.24
|
| Rate for Payer: University Health Alliance Commercial |
$12,548.76
|
|
|
Ijs-E Base Plate Assembly Ijs-Elb-Bpa [3643999]
|
Facility
|
OP
|
$22,408.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643999
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,428.33 |
| Max. Negotiated Rate |
$21,736.24 |
| Rate for Payer: Cash Price |
$14,565.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,685.95
|
| Rate for Payer: Health Management Network Commercial |
$19,047.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,117.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11,428.33
|
| Rate for Payer: MDX Hawaii PPO |
$21,736.24
|
| Rate for Payer: University Health Alliance Commercial |
$12,548.76
|
|
|
Ijs-E Drill Cann Distal Cutting 2.7mmx70mm IJS-CDC-2770 [3643989]
|
Facility
|
OP
|
$1,481.50
|
|
| Hospital Charge Code |
3643989
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$755.57 |
| Max. Negotiated Rate |
$1,437.06 |
| Rate for Payer: Cash Price |
$962.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,407.42
|
| Rate for Payer: Health Management Network Commercial |
$1,259.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$933.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$755.57
|
| Rate for Payer: MDX Hawaii PPO |
$1,437.06
|
| Rate for Payer: University Health Alliance Commercial |
$1,079.87
|
|
|
Ijs-E Drill Cann Distal Cutting 2.7mmx70mm IJS-CDC-2770 [3643989]
|
Facility
|
IP
|
$1,481.50
|
|
| Hospital Charge Code |
3643989
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,259.28 |
| Max. Negotiated Rate |
$1,437.06 |
| Rate for Payer: Cash Price |
$962.98
|
| Rate for Payer: Health Management Network Commercial |
$1,259.28
|
| Rate for Payer: MDX Hawaii PPO |
$1,437.06
|
|
|
IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS
|
Facility
|
OP
|
$4,035.20
|
|
|
Service Code
|
CPT 10030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$836.55
|
| Rate for Payer: AlohaCare Medicare |
$836.55
|
| Rate for Payer: Devoted Health Medicare |
$920.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,833.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$836.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$407.95
|
| Rate for Payer: Humana Medicare |
$836.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$836.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$920.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$836.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$836.55
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
IMETELSTAT 188 MG IV RECON.SOLN.
|
Facility
|
OP
|
$13,609.90
|
|
|
Service Code
|
HCPCS J0870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.02 |
| Max. Negotiated Rate |
$13,201.60 |
| Rate for Payer: AlohaCare Medicaid |
$58.17
|
| Rate for Payer: AlohaCare Medicare |
$58.17
|
| Rate for Payer: Cash Price |
$8,846.44
|
| Rate for Payer: Cash Price |
$8,846.44
|
| Rate for Payer: Devoted Health Medicare |
$63.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$57.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$72.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$57.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,929.41
|
| Rate for Payer: Health Management Network Commercial |
$11,568.42
|
| Rate for Payer: Humana Medicare |
$58.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,574.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,941.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.17
|
| Rate for Payer: MDX Hawaii PPO |
$13,201.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,165.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.17
|
| Rate for Payer: University Health Alliance Commercial |
$9,920.26
|
|
|
IMETELSTAT 188 MG IV RECON.SOLN.
|
Facility
|
IP
|
$13,609.90
|
|
|
Service Code
|
HCPCS J0870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,568.42 |
| Max. Negotiated Rate |
$13,201.60 |
| Rate for Payer: Cash Price |
$8,846.44
|
| Rate for Payer: Health Management Network Commercial |
$11,568.42
|
| Rate for Payer: MDX Hawaii PPO |
$13,201.60
|
|
|
IMETELSTAT 47 MG IV RECON.SOLN.
|
Facility
|
OP
|
$4,241.28
|
|
|
Service Code
|
HCPCS J0870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.02 |
| Max. Negotiated Rate |
$4,114.04 |
| Rate for Payer: AlohaCare Medicaid |
$58.17
|
| Rate for Payer: AlohaCare Medicare |
$58.17
|
| Rate for Payer: Cash Price |
$2,756.83
|
| Rate for Payer: Cash Price |
$2,756.83
|
| Rate for Payer: Devoted Health Medicare |
$63.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$57.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$72.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$57.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,029.22
|
| Rate for Payer: Health Management Network Commercial |
$3,605.09
|
| Rate for Payer: Humana Medicare |
$58.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,672.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,163.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.17
|
| Rate for Payer: MDX Hawaii PPO |
$4,114.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,544.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.17
|
| Rate for Payer: University Health Alliance Commercial |
$3,091.47
|
|
|
IMETELSTAT 47 MG IV RECON.SOLN.
|
Facility
|
IP
|
$4,241.28
|
|
|
Service Code
|
HCPCS J0870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,605.09 |
| Max. Negotiated Rate |
$4,114.04 |
| Rate for Payer: Cash Price |
$2,756.83
|
| Rate for Payer: Health Management Network Commercial |
$3,605.09
|
| Rate for Payer: MDX Hawaii PPO |
$4,114.04
|
|
|
IMIPENEM-CILASTATIN 500 MG IV RECON.SOLN.
|
Facility
|
IP
|
$99.15
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$96.18 |
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Cash Price |
$92.38
|
| Rate for Payer: Cash Price |
$41.88
|
| Rate for Payer: Health Management Network Commercial |
$120.80
|
| Rate for Payer: Health Management Network Commercial |
$54.77
|
| Rate for Payer: Health Management Network Commercial |
$84.28
|
| Rate for Payer: MDX Hawaii PPO |
$137.86
|
| Rate for Payer: MDX Hawaii PPO |
$96.18
|
| Rate for Payer: MDX Hawaii PPO |
$62.50
|
|
|
IMIPENEM-CILASTATIN 500 MG IV RECON.SOLN.
|
Facility
|
OP
|
$64.43
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$62.50 |
| Rate for Payer: Cash Price |
$41.88
|
| Rate for Payer: Cash Price |
$92.38
|
| Rate for Payer: Cash Price |
$92.38
|
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Cash Price |
$64.45
|
| Rate for Payer: Cash Price |
$41.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.19
|
| Rate for Payer: Health Management Network Commercial |
$54.77
|
| Rate for Payer: Health Management Network Commercial |
$120.80
|
| Rate for Payer: Health Management Network Commercial |
$84.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.57
|
| Rate for Payer: MDX Hawaii PPO |
$96.18
|
| Rate for Payer: MDX Hawaii PPO |
$137.86
|
| Rate for Payer: MDX Hawaii PPO |
$62.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$85.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.66
|
| Rate for Payer: University Health Alliance Commercial |
$72.27
|
| Rate for Payer: University Health Alliance Commercial |
$103.59
|
| Rate for Payer: University Health Alliance Commercial |
$46.96
|
|
|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
|
IP
|
$1,226.91
|
|
|
Service Code
|
HCPCS J1460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,042.87 |
| Max. Negotiated Rate |
$1,190.10 |
| Rate for Payer: Cash Price |
$797.49
|
| Rate for Payer: Cash Price |
$296.39
|
| Rate for Payer: Health Management Network Commercial |
$1,042.87
|
| Rate for Payer: Health Management Network Commercial |
$387.59
|
| Rate for Payer: MDX Hawaii PPO |
$1,190.10
|
| Rate for Payer: MDX Hawaii PPO |
$442.31
|
|
|
IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN
|
Facility
|
OP
|
$455.99
|
|
|
Service Code
|
HCPCS J1460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$442.31 |
| Rate for Payer: AlohaCare Medicaid |
$48.95
|
| Rate for Payer: AlohaCare Medicaid |
$48.95
|
| Rate for Payer: AlohaCare Medicare |
$48.95
|
| Rate for Payer: AlohaCare Medicare |
$48.95
|
| Rate for Payer: Cash Price |
$296.39
|
| Rate for Payer: Cash Price |
$296.39
|
| Rate for Payer: Cash Price |
$797.49
|
| Rate for Payer: Cash Price |
$797.49
|
| Rate for Payer: Devoted Health Medicare |
$53.84
|
| Rate for Payer: Devoted Health Medicare |
$53.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.19
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$48.42
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$48.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,165.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$433.19
|
| Rate for Payer: Health Management Network Commercial |
$1,042.87
|
| Rate for Payer: Health Management Network Commercial |
$387.59
|
| Rate for Payer: Humana Medicare |
$48.95
|
| Rate for Payer: Humana Medicare |
$48.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$772.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$287.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$232.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$625.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.95
|
| Rate for Payer: MDX Hawaii PPO |
$442.31
|
| Rate for Payer: MDX Hawaii PPO |
$1,190.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$273.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$736.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.95
|
| Rate for Payer: University Health Alliance Commercial |
$332.37
|
| Rate for Payer: University Health Alliance Commercial |
$894.29
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (20 GM) 10 % 200 ML INJ
|
Facility
|
IP
|
$5,723.04
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,864.58 |
| Max. Negotiated Rate |
$5,551.35 |
| Rate for Payer: Cash Price |
$3,719.98
|
| Rate for Payer: Health Management Network Commercial |
$4,864.58
|
| Rate for Payer: MDX Hawaii PPO |
$5,551.35
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (20 GM) 10 % 200 ML INJ
|
Facility
|
OP
|
$5,723.04
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$5,551.35 |
| Rate for Payer: AlohaCare Medicaid |
$49.53
|
| Rate for Payer: AlohaCare Medicare |
$49.53
|
| Rate for Payer: Cash Price |
$3,719.98
|
| Rate for Payer: Cash Price |
$3,719.98
|
| Rate for Payer: Devoted Health Medicare |
$54.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,436.89
|
| Rate for Payer: Health Management Network Commercial |
$4,864.58
|
| Rate for Payer: Humana Medicare |
$49.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,605.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,918.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.53
|
| Rate for Payer: MDX Hawaii PPO |
$5,551.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,433.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.53
|
| Rate for Payer: University Health Alliance Commercial |
$4,171.52
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (40 GM) 10% 400 ML INJ
|
Facility
|
OP
|
$10,327.68
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$10,017.85 |
| Rate for Payer: AlohaCare Medicaid |
$49.53
|
| Rate for Payer: AlohaCare Medicare |
$49.53
|
| Rate for Payer: Cash Price |
$6,712.99
|
| Rate for Payer: Cash Price |
$6,712.99
|
| Rate for Payer: Devoted Health Medicare |
$54.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,811.30
|
| Rate for Payer: Health Management Network Commercial |
$8,778.53
|
| Rate for Payer: Humana Medicare |
$49.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,506.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,267.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.53
|
| Rate for Payer: MDX Hawaii PPO |
$10,017.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,196.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.53
|
| Rate for Payer: University Health Alliance Commercial |
$7,527.85
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (40 GM) 10% 400 ML INJ
|
Facility
|
IP
|
$10,327.68
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,778.53 |
| Max. Negotiated Rate |
$10,017.85 |
| Rate for Payer: Cash Price |
$6,712.99
|
| Rate for Payer: Health Management Network Commercial |
$8,778.53
|
| Rate for Payer: MDX Hawaii PPO |
$10,017.85
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (5 GM) 10 % 50 ML INJ
|
Facility
|
IP
|
$2,231.51
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,896.78 |
| Max. Negotiated Rate |
$2,164.56 |
| Rate for Payer: Cash Price |
$1,450.48
|
| Rate for Payer: Health Management Network Commercial |
$1,896.78
|
| Rate for Payer: MDX Hawaii PPO |
$2,164.56
|
|
|
IMMUNE GLOBULIN (HUMAN) (IGG) (5 GM) 10 % 50 ML INJ
|
Facility
|
OP
|
$2,231.51
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$2,164.56 |
| Rate for Payer: AlohaCare Medicaid |
$49.53
|
| Rate for Payer: AlohaCare Medicare |
$49.53
|
| Rate for Payer: Cash Price |
$1,450.48
|
| Rate for Payer: Cash Price |
$1,450.48
|
| Rate for Payer: Devoted Health Medicare |
$54.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,119.93
|
| Rate for Payer: Health Management Network Commercial |
$1,896.78
|
| Rate for Payer: Humana Medicare |
$49.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,405.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,138.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.53
|
| Rate for Payer: MDX Hawaii PPO |
$2,164.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,338.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.53
|
| Rate for Payer: University Health Alliance Commercial |
$1,626.55
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
|
IP
|
$3,420.72
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,907.61 |
| Max. Negotiated Rate |
$3,318.10 |
| Rate for Payer: Cash Price |
$2,223.47
|
| Rate for Payer: Health Management Network Commercial |
$2,907.61
|
| Rate for Payer: MDX Hawaii PPO |
$3,318.10
|
|
|
IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN
|
Facility
|
OP
|
$3,420.72
|
|
|
Service Code
|
HCPCS J1459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$3,318.10 |
| Rate for Payer: AlohaCare Medicaid |
$49.53
|
| Rate for Payer: AlohaCare Medicare |
$49.53
|
| Rate for Payer: Cash Price |
$2,223.47
|
| Rate for Payer: Cash Price |
$2,223.47
|
| Rate for Payer: Devoted Health Medicare |
$54.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$50.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,249.68
|
| Rate for Payer: Health Management Network Commercial |
$2,907.61
|
| Rate for Payer: Humana Medicare |
$49.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,155.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,744.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.53
|
| Rate for Payer: MDX Hawaii PPO |
$3,318.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,052.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.53
|
| Rate for Payer: University Health Alliance Commercial |
$2,493.36
|
|
|
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 15-3
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
HCPCS 86300
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: AlohaCare Medicaid |
$28.76
|
| Rate for Payer: AlohaCare Medicare |
$20.81
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Devoted Health Medicare |
$22.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.75
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.81
|
|
|
IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
HCPCS 86301
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: AlohaCare Medicaid |
$28.76
|
| Rate for Payer: AlohaCare Medicare |
$20.81
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Devoted Health Medicare |
$22.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.75
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.81
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$91,492.03
|
|
|
Service Code
|
APR-DRG 1613
|
| Min. Negotiated Rate |
$91,492.03 |
| Max. Negotiated Rate |
$91,492.03 |
| Rate for Payer: AlohaCare Medicaid |
$91,492.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$91,492.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$91,492.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91,492.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91,492.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91,492.03
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$52,037.63
|
|
|
Service Code
|
APR-DRG 1611
|
| Min. Negotiated Rate |
$52,037.63 |
| Max. Negotiated Rate |
$52,037.63 |
| Rate for Payer: AlohaCare Medicaid |
$52,037.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$52,037.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$52,037.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52,037.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52,037.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52,037.63
|
|
