|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$44.18
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$42.85 |
| Rate for Payer: Cash Price |
$28.72
|
| Rate for Payer: Cash Price |
$8.51
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$8.51
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cash Price |
$28.72
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.44
|
| Rate for Payer: Health Management Network Commercial |
$15.06
|
| Rate for Payer: Health Management Network Commercial |
$41.83
|
| Rate for Payer: Health Management Network Commercial |
$11.13
|
| Rate for Payer: Health Management Network Commercial |
$23.94
|
| Rate for Payer: Health Management Network Commercial |
$37.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.36
|
| Rate for Payer: MDX Hawaii PPO |
$27.32
|
| Rate for Payer: MDX Hawaii PPO |
$47.73
|
| Rate for Payer: MDX Hawaii PPO |
$42.85
|
| Rate for Payer: MDX Hawaii PPO |
$12.70
|
| Rate for Payer: MDX Hawaii PPO |
$17.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.53
|
| Rate for Payer: University Health Alliance Commercial |
$12.92
|
| Rate for Payer: University Health Alliance Commercial |
$20.53
|
| Rate for Payer: University Health Alliance Commercial |
$32.20
|
| Rate for Payer: University Health Alliance Commercial |
$35.87
|
| Rate for Payer: University Health Alliance Commercial |
$9.54
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$44.18
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.55 |
| Max. Negotiated Rate |
$42.85 |
| Rate for Payer: Cash Price |
$28.72
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cash Price |
$8.51
|
| Rate for Payer: Health Management Network Commercial |
$23.94
|
| Rate for Payer: Health Management Network Commercial |
$11.13
|
| Rate for Payer: Health Management Network Commercial |
$15.06
|
| Rate for Payer: Health Management Network Commercial |
$37.55
|
| Rate for Payer: Health Management Network Commercial |
$41.83
|
| Rate for Payer: MDX Hawaii PPO |
$47.73
|
| Rate for Payer: MDX Hawaii PPO |
$42.85
|
| Rate for Payer: MDX Hawaii PPO |
$12.70
|
| Rate for Payer: MDX Hawaii PPO |
$27.32
|
| Rate for Payer: MDX Hawaii PPO |
$17.19
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$19.55
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$18.96 |
| Rate for Payer: Cash Price |
$12.71
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Cash Price |
$31.04
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$31.04
|
| Rate for Payer: Cash Price |
$12.71
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.80
|
| Rate for Payer: Health Management Network Commercial |
$13.01
|
| Rate for Payer: Health Management Network Commercial |
$40.60
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Health Management Network Commercial |
$16.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.45
|
| Rate for Payer: MDX Hawaii PPO |
$16.06
|
| Rate for Payer: MDX Hawaii PPO |
$46.33
|
| Rate for Payer: MDX Hawaii PPO |
$18.96
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: MDX Hawaii PPO |
$14.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.66
|
| Rate for Payer: University Health Alliance Commercial |
$11.15
|
| Rate for Payer: University Health Alliance Commercial |
$12.07
|
| Rate for Payer: University Health Alliance Commercial |
$14.25
|
| Rate for Payer: University Health Alliance Commercial |
$34.81
|
| Rate for Payer: University Health Alliance Commercial |
$9.05
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$19.55
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$18.96 |
| Rate for Payer: Cash Price |
$12.71
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$31.04
|
| Rate for Payer: Cash Price |
$8.07
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Health Management Network Commercial |
$10.56
|
| Rate for Payer: Health Management Network Commercial |
$13.01
|
| Rate for Payer: Health Management Network Commercial |
$16.62
|
| Rate for Payer: Health Management Network Commercial |
$40.60
|
| Rate for Payer: MDX Hawaii PPO |
$46.33
|
| Rate for Payer: MDX Hawaii PPO |
$18.96
|
| Rate for Payer: MDX Hawaii PPO |
$12.05
|
| Rate for Payer: MDX Hawaii PPO |
$16.06
|
| Rate for Payer: MDX Hawaii PPO |
$14.84
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$19.77
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$19.18 |
| Rate for Payer: Cash Price |
$12.85
|
| Rate for Payer: Cash Price |
$12.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.78
|
| Rate for Payer: Health Management Network Commercial |
$16.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.08
|
| Rate for Payer: MDX Hawaii PPO |
$19.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.86
|
| Rate for Payer: University Health Alliance Commercial |
$14.41
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$19.77
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$19.18 |
| Rate for Payer: Cash Price |
$12.85
|
| Rate for Payer: Health Management Network Commercial |
$16.80
|
| Rate for Payer: MDX Hawaii PPO |
$19.18
|
|
|
BUPRENORPHINE HCL 2 MG SL SUBL.TAB
|
Facility
|
OP
|
$13.53
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.80
|
| Rate for Payer: Health Management Network Commercial |
$11.50
|
| Rate for Payer: Health Management Network Commercial |
$2.51
|
| Rate for Payer: Health Management Network Commercial |
$19.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.66
|
| Rate for Payer: MDX Hawaii PPO |
$13.12
|
| Rate for Payer: MDX Hawaii PPO |
$22.17
|
| Rate for Payer: MDX Hawaii PPO |
$2.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.77
|
| Rate for Payer: University Health Alliance Commercial |
$2.15
|
| Rate for Payer: University Health Alliance Commercial |
$16.66
|
| Rate for Payer: University Health Alliance Commercial |
$9.86
|
|
|
BUPRENORPHINE HCL 2 MG SL SUBL.TAB
|
Facility
|
IP
|
$22.86
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.43 |
| Max. Negotiated Rate |
$22.17 |
| Rate for Payer: Cash Price |
$14.86
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Management Network Commercial |
$11.50
|
| Rate for Payer: Health Management Network Commercial |
$19.43
|
| Rate for Payer: Health Management Network Commercial |
$2.51
|
| Rate for Payer: MDX Hawaii PPO |
$22.17
|
| Rate for Payer: MDX Hawaii PPO |
$2.86
|
| Rate for Payer: MDX Hawaii PPO |
$13.12
|
|
|
BUPRENORPHINE HCL 8 MG SL SUBL.TAB
|
Facility
|
IP
|
$23.19
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.71 |
| Max. Negotiated Rate |
$22.49 |
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Cash Price |
$30.58
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Health Management Network Commercial |
$39.98
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
| Rate for Payer: MDX Hawaii PPO |
$45.63
|
|
|
BUPRENORPHINE HCL 8 MG SL SUBL.TAB
|
Facility
|
OP
|
$47.04
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.99 |
| Max. Negotiated Rate |
$45.63 |
| Rate for Payer: Cash Price |
$30.58
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.69
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Health Management Network Commercial |
$39.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.83
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
| Rate for Payer: MDX Hawaii PPO |
$45.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.22
|
| Rate for Payer: University Health Alliance Commercial |
$34.29
|
| Rate for Payer: University Health Alliance Commercial |
$16.90
|
|
|
BUPROPION 150 MG PO TAB EXTENDED RELEASE 24 HR (XL)
|
Facility
|
OP
|
$12.26
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.25 |
| Max. Negotiated Rate |
$11.89 |
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.03
|
| Rate for Payer: Health Management Network Commercial |
$10.42
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.90
|
| Rate for Payer: MDX Hawaii PPO |
$11.89
|
| Rate for Payer: MDX Hawaii PPO |
$24.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.36
|
| Rate for Payer: University Health Alliance Commercial |
$8.94
|
| Rate for Payer: University Health Alliance Commercial |
$18.43
|
|
|
BUPROPION 150 MG PO TAB EXTENDED RELEASE 24 HR (XL)
|
Facility
|
IP
|
$12.26
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.42 |
| Max. Negotiated Rate |
$11.89 |
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Health Management Network Commercial |
$10.42
|
| Rate for Payer: MDX Hawaii PPO |
$11.89
|
| Rate for Payer: MDX Hawaii PPO |
$24.53
|
|
|
BUPROPION HCL 100 MG PO SR12
|
Facility
|
IP
|
$9.19
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Health Management Network Commercial |
$7.81
|
| Rate for Payer: Health Management Network Commercial |
$7.93
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: MDX Hawaii PPO |
$9.05
|
| Rate for Payer: MDX Hawaii PPO |
$8.91
|
|
|
BUPROPION HCL 100 MG PO SR12
|
Facility
|
OP
|
$9.19
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.73
|
| Rate for Payer: Health Management Network Commercial |
$7.93
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Health Management Network Commercial |
$7.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.46
|
| Rate for Payer: MDX Hawaii PPO |
$9.05
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: MDX Hawaii PPO |
$8.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.60
|
| Rate for Payer: University Health Alliance Commercial |
$6.80
|
| Rate for Payer: University Health Alliance Commercial |
$7.81
|
| Rate for Payer: University Health Alliance Commercial |
$6.70
|
|
|
BUPROPION HCL 150 MG PO SR12
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.15
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.45
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.41
|
| Rate for Payer: University Health Alliance Commercial |
$7.78
|
|
|
BUPROPION HCL 150 MG PO SR12
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
|
|
BUPROPION HCL 200 MG PO SR12
|
Facility
|
OP
|
$18.65
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$18.09 |
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.72
|
| Rate for Payer: Health Management Network Commercial |
$15.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.51
|
| Rate for Payer: MDX Hawaii PPO |
$18.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.19
|
| Rate for Payer: University Health Alliance Commercial |
$13.59
|
|
|
BUPROPION HCL 200 MG PO SR12
|
Facility
|
IP
|
$18.65
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$18.09 |
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Health Management Network Commercial |
$15.85
|
| Rate for Payer: MDX Hawaii PPO |
$18.09
|
|
|
BUPROPION HCL 75 MG PO TABLET
|
Facility
|
IP
|
$6.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Health Management Network Commercial |
$6.18
|
| Rate for Payer: Health Management Network Commercial |
$5.68
|
| Rate for Payer: MDX Hawaii PPO |
$6.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.05
|
|
|
BUPROPION HCL 75 MG PO TABLET
|
Facility
|
OP
|
$6.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.91
|
| Rate for Payer: Health Management Network Commercial |
$5.68
|
| Rate for Payer: Health Management Network Commercial |
$6.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.71
|
| Rate for Payer: MDX Hawaii PPO |
$6.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.01
|
| Rate for Payer: University Health Alliance Commercial |
$4.87
|
| Rate for Payer: University Health Alliance Commercial |
$5.30
|
|
|
Bur 4.0mm Egg 1608-002-035 [3643637]
|
Facility
|
OP
|
$424.23
|
|
| Hospital Charge Code |
3643637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$216.36 |
| Max. Negotiated Rate |
$411.50 |
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$403.02
|
| Rate for Payer: Health Management Network Commercial |
$360.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$267.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$216.36
|
| Rate for Payer: MDX Hawaii PPO |
$411.50
|
| Rate for Payer: University Health Alliance Commercial |
$309.22
|
|
|
Bur 4.0mm Egg 1608-002-035 [3643637]
|
Facility
|
IP
|
$424.23
|
|
| Hospital Charge Code |
3643637
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.60 |
| Max. Negotiated Rate |
$411.50 |
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Health Management Network Commercial |
$360.60
|
| Rate for Payer: MDX Hawaii PPO |
$411.50
|
|
|
Bur 6.0mm Egg 1607-002-003 [3643636]
|
Facility
|
IP
|
$424.23
|
|
| Hospital Charge Code |
3643636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.60 |
| Max. Negotiated Rate |
$411.50 |
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Health Management Network Commercial |
$360.60
|
| Rate for Payer: MDX Hawaii PPO |
$411.50
|
|
|
Bur 6.0mm Egg 1607-002-003 [3643636]
|
Facility
|
OP
|
$424.23
|
|
| Hospital Charge Code |
3643636
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$216.36 |
| Max. Negotiated Rate |
$411.50 |
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$403.02
|
| Rate for Payer: Health Management Network Commercial |
$360.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$267.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$216.36
|
| Rate for Payer: MDX Hawaii PPO |
$411.50
|
| Rate for Payer: University Health Alliance Commercial |
$309.22
|
|
|
BURNS W SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS
|
Facility
|
IP
|
$6,678.79
|
|
|
Service Code
|
APR-DRG 8421
|
| Min. Negotiated Rate |
$6,678.79 |
| Max. Negotiated Rate |
$6,678.79 |
| Rate for Payer: AlohaCare Medicaid |
$6,678.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6,678.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6,678.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,678.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,678.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,678.79
|
|
