|
Acetone, Serum FSI
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8128106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
Acetone, Serum FSI
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8128106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$60.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Devoted Health Medicare |
$66.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.17
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$60.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.13
|
|
|
Acetylcholine Receptor Binding Antibody FSI
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
8117761
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
|
|
Acetylcholine Receptor Binding Antibody FSI
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
8117761
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: AlohaCare Medicaid |
$77.00
|
| Rate for Payer: AlohaCare Medicare |
$77.00
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Devoted Health Medicare |
$84.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.67
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.40
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Humana Medicare |
$77.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$77.00
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.00
|
| Rate for Payer: University Health Alliance Commercial |
$34.93
|
|
|
acetylcysteine 200mg/ml vial (IV) 30ml [HHSC]
|
Facility
|
OP
|
$618.20
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$599.65 |
| Rate for Payer: Kaiser Permanente Medicare |
$356.75
|
| Rate for Payer: AlohaCare Medicaid |
$309.10
|
| Rate for Payer: AlohaCare Medicaid |
$166.03
|
| Rate for Payer: AlohaCare Medicaid |
$356.75
|
| Rate for Payer: AlohaCare Medicaid |
$486.75
|
| Rate for Payer: AlohaCare Medicaid |
$113.22
|
| Rate for Payer: AlohaCare Medicare |
$309.10
|
| Rate for Payer: AlohaCare Medicare |
$356.75
|
| Rate for Payer: AlohaCare Medicare |
$486.75
|
| Rate for Payer: AlohaCare Medicare |
$113.22
|
| Rate for Payer: AlohaCare Medicare |
$166.03
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Devoted Health Medicare |
$340.01
|
| Rate for Payer: Devoted Health Medicare |
$124.55
|
| Rate for Payer: Devoted Health Medicare |
$392.43
|
| Rate for Payer: Devoted Health Medicare |
$535.42
|
| Rate for Payer: Devoted Health Medicare |
$182.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$166.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$113.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$309.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$486.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$587.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$215.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$315.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$677.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$924.83
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Health Management Network Commercial |
$282.26
|
| Rate for Payer: Health Management Network Commercial |
$192.48
|
| Rate for Payer: Health Management Network Commercial |
$827.48
|
| Rate for Payer: Health Management Network Commercial |
$606.48
|
| Rate for Payer: Humana Medicare |
$309.10
|
| Rate for Payer: Humana Medicare |
$113.22
|
| Rate for Payer: Humana Medicare |
$166.03
|
| Rate for Payer: Humana Medicare |
$356.75
|
| Rate for Payer: Humana Medicare |
$486.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$642.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$876.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$298.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$169.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$496.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$166.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$309.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$486.75
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
| Rate for Payer: MDX Hawaii PPO |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$322.11
|
| Rate for Payer: MDX Hawaii PPO |
$219.66
|
| Rate for Payer: MDX Hawaii PPO |
$944.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$166.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$486.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$486.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$166.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$113.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$370.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$584.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$428.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$199.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$113.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$166.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$486.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$309.10
|
| Rate for Payer: University Health Alliance Commercial |
$165.06
|
| Rate for Payer: University Health Alliance Commercial |
$450.61
|
| Rate for Payer: University Health Alliance Commercial |
$520.07
|
| Rate for Payer: University Health Alliance Commercial |
$242.05
|
| Rate for Payer: University Health Alliance Commercial |
$709.58
|
|
|
acetylcysteine 200mg/ml vial (IV) 30ml [HHSC]
|
Facility
|
IP
|
$713.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$606.48 |
| Max. Negotiated Rate |
$692.10 |
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Health Management Network Commercial |
$606.48
|
| Rate for Payer: Health Management Network Commercial |
$827.48
|
| Rate for Payer: Health Management Network Commercial |
$282.26
|
| Rate for Payer: Health Management Network Commercial |
$192.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$298.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$642.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$876.15
|
| Rate for Payer: MDX Hawaii PPO |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$322.11
|
| Rate for Payer: MDX Hawaii PPO |
$219.66
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
| Rate for Payer: MDX Hawaii PPO |
$944.29
|
|
|
acetylcysteine 20% 30 mL vial [HHSC]
|
Facility
|
OP
|
$122.68
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: AlohaCare Medicaid |
$61.34
|
| Rate for Payer: AlohaCare Medicaid |
$33.66
|
| Rate for Payer: AlohaCare Medicaid |
$74.31
|
| Rate for Payer: AlohaCare Medicare |
$74.31
|
| Rate for Payer: AlohaCare Medicare |
$61.34
|
| Rate for Payer: AlohaCare Medicare |
$33.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Devoted Health Medicare |
$67.47
|
| Rate for Payer: Devoted Health Medicare |
$37.03
|
| Rate for Payer: Devoted Health Medicare |
$81.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.96
|
| Rate for Payer: Health Management Network Commercial |
$57.23
|
| Rate for Payer: Health Management Network Commercial |
$104.28
|
| Rate for Payer: Health Management Network Commercial |
$126.33
|
| Rate for Payer: Humana Medicare |
$61.34
|
| Rate for Payer: Humana Medicare |
$74.31
|
| Rate for Payer: Humana Medicare |
$33.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.66
|
| Rate for Payer: MDX Hawaii PPO |
$65.31
|
| Rate for Payer: MDX Hawaii PPO |
$144.16
|
| Rate for Payer: MDX Hawaii PPO |
$119.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.66
|
| Rate for Payer: University Health Alliance Commercial |
$89.42
|
| Rate for Payer: University Health Alliance Commercial |
$108.33
|
| Rate for Payer: University Health Alliance Commercial |
$49.08
|
|
|
acetylcysteine 20% 30 mL vial [HHSC]
|
Facility
|
IP
|
$67.33
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.23 |
| Max. Negotiated Rate |
$65.31 |
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Health Management Network Commercial |
$104.28
|
| Rate for Payer: Health Management Network Commercial |
$57.23
|
| Rate for Payer: Health Management Network Commercial |
$126.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.41
|
| Rate for Payer: MDX Hawaii PPO |
$144.16
|
| Rate for Payer: MDX Hawaii PPO |
$119.00
|
| Rate for Payer: MDX Hawaii PPO |
$65.31
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
OP
|
$142.25
|
|
|
Service Code
|
NDC 66689020204
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.12 |
| Max. Negotiated Rate |
$137.98 |
| Rate for Payer: AlohaCare Medicaid |
$71.12
|
| Rate for Payer: AlohaCare Medicare |
$71.12
|
| Rate for Payer: Cash Price |
$92.46
|
| Rate for Payer: Devoted Health Medicare |
$78.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.14
|
| Rate for Payer: Health Management Network Commercial |
$120.91
|
| Rate for Payer: Humana Medicare |
$71.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.12
|
| Rate for Payer: MDX Hawaii PPO |
$137.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$85.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.12
|
| Rate for Payer: University Health Alliance Commercial |
$103.69
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
OP
|
$87.96
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.98 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: AlohaCare Medicaid |
$43.98
|
| Rate for Payer: AlohaCare Medicare |
$43.98
|
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Devoted Health Medicare |
$48.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.56
|
| Rate for Payer: Health Management Network Commercial |
$74.77
|
| Rate for Payer: Humana Medicare |
$43.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.98
|
| Rate for Payer: MDX Hawaii PPO |
$85.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.98
|
| Rate for Payer: University Health Alliance Commercial |
$64.11
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
IP
|
$87.96
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Health Management Network Commercial |
$74.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.16
|
| Rate for Payer: MDX Hawaii PPO |
$85.32
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
IP
|
$142.25
|
|
|
Service Code
|
NDC 66689020204
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.91 |
| Max. Negotiated Rate |
$137.98 |
| Rate for Payer: Cash Price |
$92.46
|
| Rate for Payer: Health Management Network Commercial |
$120.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.03
|
| Rate for Payer: MDX Hawaii PPO |
$137.98
|
|
|
ACTIVATION TOOL
|
Facility
|
IP
|
$219.00
|
|
| Hospital Charge Code |
12969391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.15 |
| Max. Negotiated Rate |
$212.43 |
| Rate for Payer: Cash Price |
$142.35
|
| Rate for Payer: Health Management Network Commercial |
$186.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$197.10
|
| Rate for Payer: MDX Hawaii PPO |
$212.43
|
|
|
ACTIVATION TOOL
|
Facility
|
OP
|
$219.00
|
|
| Hospital Charge Code |
12969391
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.50 |
| Max. Negotiated Rate |
$212.43 |
| Rate for Payer: AlohaCare Medicaid |
$109.50
|
| Rate for Payer: AlohaCare Medicare |
$109.50
|
| Rate for Payer: Cash Price |
$142.35
|
| Rate for Payer: Devoted Health Medicare |
$120.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$208.05
|
| Rate for Payer: Health Management Network Commercial |
$186.15
|
| Rate for Payer: Humana Medicare |
$109.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$197.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.50
|
| Rate for Payer: MDX Hawaii PPO |
$212.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.50
|
| Rate for Payer: University Health Alliance Commercial |
$159.63
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$117.01
|
|
|
Service Code
|
NDC 00574012076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.46 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$187.40
|
|
|
Service Code
|
NDC 66689020308
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.29 |
| Max. Negotiated Rate |
$181.78 |
| Rate for Payer: Cash Price |
$121.81
|
| Rate for Payer: Health Management Network Commercial |
$159.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$168.66
|
| Rate for Payer: MDX Hawaii PPO |
$181.78
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$117.01
|
|
|
Service Code
|
NDC 00574052076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.51 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: AlohaCare Medicaid |
$58.51
|
| Rate for Payer: AlohaCare Medicare |
$58.51
|
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Devoted Health Medicare |
$64.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.16
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Humana Medicare |
$58.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.51
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.51
|
| Rate for Payer: University Health Alliance Commercial |
$85.29
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
IP
|
$117.01
|
|
|
Service Code
|
NDC 00574052076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.46 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$117.01
|
|
|
Service Code
|
NDC 00574012076
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.51 |
| Max. Negotiated Rate |
$113.50 |
| Rate for Payer: AlohaCare Medicaid |
$58.51
|
| Rate for Payer: AlohaCare Medicare |
$58.51
|
| Rate for Payer: Cash Price |
$76.06
|
| Rate for Payer: Devoted Health Medicare |
$64.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.16
|
| Rate for Payer: Health Management Network Commercial |
$99.46
|
| Rate for Payer: Humana Medicare |
$58.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.51
|
| Rate for Payer: MDX Hawaii PPO |
$113.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.51
|
| Rate for Payer: University Health Alliance Commercial |
$85.29
|
|
|
activ charcoal-sorbitol 50 gm/240 mL [HHSC]
|
Facility
|
OP
|
$187.40
|
|
|
Service Code
|
NDC 66689020308
|
| Hospital Charge Code |
2500171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.70 |
| Max. Negotiated Rate |
$181.78 |
| Rate for Payer: AlohaCare Medicaid |
$93.70
|
| Rate for Payer: AlohaCare Medicare |
$93.70
|
| Rate for Payer: Cash Price |
$121.81
|
| Rate for Payer: Devoted Health Medicare |
$103.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$178.03
|
| Rate for Payer: Health Management Network Commercial |
$159.29
|
| Rate for Payer: Humana Medicare |
$93.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$168.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.70
|
| Rate for Payer: MDX Hawaii PPO |
$181.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$112.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.70
|
| Rate for Payer: University Health Alliance Commercial |
$136.60
|
|
|
ACUMEN IQ ADJUSTABLE CUFF
|
Facility
|
OP
|
$1,523.00
|
|
| Hospital Charge Code |
10526812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$761.50 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: AlohaCare Medicaid |
$761.50
|
| Rate for Payer: AlohaCare Medicare |
$761.50
|
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Devoted Health Medicare |
$837.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$761.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,446.85
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Humana Medicare |
$761.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$776.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$761.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$761.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$761.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$761.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,110.11
|
|
|
ACUMEN IQ ADJUSTABLE CUFF
|
Facility
|
IP
|
$1,523.00
|
|
| Hospital Charge Code |
10526812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,294.55 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
|
|
ACUMEN IQ SENSOR 84/213CM
|
Facility
|
IP
|
$1,523.00
|
|
| Hospital Charge Code |
10526814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,294.55 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
|
|
ACUMEN IQ SENSOR 84/213CM
|
Facility
|
OP
|
$1,523.00
|
|
| Hospital Charge Code |
10526814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$761.50 |
| Max. Negotiated Rate |
$1,477.31 |
| Rate for Payer: AlohaCare Medicaid |
$761.50
|
| Rate for Payer: AlohaCare Medicare |
$761.50
|
| Rate for Payer: Cash Price |
$989.95
|
| Rate for Payer: Devoted Health Medicare |
$837.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$761.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,446.85
|
| Rate for Payer: Health Management Network Commercial |
$1,294.55
|
| Rate for Payer: Humana Medicare |
$761.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,370.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$776.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$761.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,477.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$761.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$761.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$761.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,110.11
|
|
|
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION
|
Facility
|
IP
|
$11,661.38
|
|
|
Service Code
|
MSDRG 880
|
| Min. Negotiated Rate |
$11,661.38 |
| Max. Negotiated Rate |
$11,661.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11,661.38
|
|
