|
Alpha 1 Antitrypsin
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
HCPCS 82103
|
| Hospital Charge Code |
9552422
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: AlohaCare Medicaid |
$139.50
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| Rate for Payer: Cash Price |
$181.35
|
| Rate for Payer: Cash Price |
$181.35
|
| Rate for Payer: Devoted Health Medicare |
$153.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.44
|
| Rate for Payer: Health Management Network Commercial |
$237.15
|
| Rate for Payer: Humana Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$251.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$142.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$270.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| Rate for Payer: University Health Alliance Commercial |
$34.72
|
|
|
alteplase 2 mg vial [HHSC]
|
Facility
|
IP
|
$604.03
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
2500041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$513.43 |
| Max. Negotiated Rate |
$585.91 |
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Health Management Network Commercial |
$513.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.63
|
| Rate for Payer: MDX Hawaii PPO |
$585.91
|
|
|
alteplase 2 mg vial [HHSC]
|
Facility
|
OP
|
$604.03
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
2500041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$585.91 |
| Rate for Payer: AlohaCare Medicaid |
$302.01
|
| Rate for Payer: AlohaCare Medicare |
$302.01
|
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Devoted Health Medicare |
$332.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$302.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.83
|
| Rate for Payer: Health Management Network Commercial |
$513.43
|
| Rate for Payer: Humana Medicare |
$302.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$302.01
|
| Rate for Payer: MDX Hawaii PPO |
$585.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$302.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$302.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$362.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$302.01
|
| Rate for Payer: University Health Alliance Commercial |
$440.28
|
|
|
ALT (SGPT) FSI
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 84460
|
| Hospital Charge Code |
8117837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.30 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicare |
$52.50
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Devoted Health Medicare |
$57.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.30
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.69
|
|
|
ALT (SGPT) FSI
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS 84460
|
| Hospital Charge Code |
8117837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.97
|
|
|
Service Code
|
NDC 66689006099
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: AlohaCare Medicaid |
$10.98
|
| Rate for Payer: AlohaCare Medicare |
$10.98
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$12.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.87
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Humana Medicare |
$10.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.98
|
| Rate for Payer: MDX Hawaii PPO |
$21.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.98
|
| Rate for Payer: University Health Alliance Commercial |
$16.01
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.17
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$20.53 |
| Rate for Payer: MDX Hawaii PPO |
$20.53
|
| Rate for Payer: AlohaCare Medicaid |
$10.59
|
| Rate for Payer: AlohaCare Medicare |
$10.59
|
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: Devoted Health Medicare |
$11.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.11
|
| Rate for Payer: Health Management Network Commercial |
$17.99
|
| Rate for Payer: Humana Medicare |
$10.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.59
|
| Rate for Payer: University Health Alliance Commercial |
$15.43
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.97
|
|
|
Service Code
|
NDC 66689006099
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.77
|
| Rate for Payer: MDX Hawaii PPO |
$21.31
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.09
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Health Management Network Commercial |
$17.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.98
|
| Rate for Payer: MDX Hawaii PPO |
$20.46
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.99 |
| Max. Negotiated Rate |
$20.53 |
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: Health Management Network Commercial |
$17.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.05
|
| Rate for Payer: MDX Hawaii PPO |
$20.53
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.09
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: AlohaCare Medicaid |
$10.54
|
| Rate for Payer: AlohaCare Medicare |
$10.54
|
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Devoted Health Medicare |
$11.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.04
|
| Rate for Payer: Health Management Network Commercial |
$17.93
|
| Rate for Payer: Humana Medicare |
$10.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.54
|
| Rate for Payer: MDX Hawaii PPO |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.54
|
| Rate for Payer: University Health Alliance Commercial |
$15.37
|
|
|
AMB Admin Charge (nirsevimab)
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
11622779
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$14.77 |
| Max. Negotiated Rate |
$39.04 |
| Rate for Payer: AlohaCare Medicaid |
$14.77
|
| Rate for Payer: AlohaCare Medicare |
$32.53
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$35.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.53
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.53
|
|
|
amiodarone 150 mg/3mL vial [HHSC]
|
Facility
|
IP
|
$25.56
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
2500050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$24.79 |
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$21.73
|
| Rate for Payer: Health Management Network Commercial |
$14.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$16.18
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: MDX Hawaii PPO |
$24.79
|
|
|
amiodarone 150 mg/3mL vial [HHSC]
|
Facility
|
OP
|
$13.34
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
2500050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: AlohaCare Medicaid |
$6.67
|
| Rate for Payer: AlohaCare Medicaid |
$12.78
|
| Rate for Payer: AlohaCare Medicaid |
$8.34
|
| Rate for Payer: AlohaCare Medicare |
$8.34
|
| Rate for Payer: AlohaCare Medicare |
$6.67
|
| Rate for Payer: AlohaCare Medicare |
$12.78
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Devoted Health Medicare |
$7.34
|
| Rate for Payer: Devoted Health Medicare |
$14.06
|
| Rate for Payer: Devoted Health Medicare |
$9.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.28
|
| Rate for Payer: Health Management Network Commercial |
$21.73
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$14.18
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Humana Medicare |
$8.34
|
| Rate for Payer: Humana Medicare |
$12.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.78
|
| Rate for Payer: MDX Hawaii PPO |
$24.79
|
| Rate for Payer: MDX Hawaii PPO |
$16.18
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.78
|
| Rate for Payer: University Health Alliance Commercial |
$9.72
|
| Rate for Payer: University Health Alliance Commercial |
$12.16
|
| Rate for Payer: University Health Alliance Commercial |
$18.63
|
|
|
amiodarone-D5W 150 mg/100 mL premix [HHSC]
|
Facility
|
OP
|
$192.16
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2501116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$186.40 |
| Rate for Payer: AlohaCare Medicaid |
$96.08
|
| Rate for Payer: AlohaCare Medicare |
$96.08
|
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Devoted Health Medicare |
$105.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$182.55
|
| Rate for Payer: Health Management Network Commercial |
$163.34
|
| Rate for Payer: Humana Medicare |
$96.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.08
|
| Rate for Payer: MDX Hawaii PPO |
$186.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.08
|
| Rate for Payer: University Health Alliance Commercial |
$140.07
|
|
|
amiodarone-D5W 150 mg/100 mL premix [HHSC]
|
Facility
|
IP
|
$192.16
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2501116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.34 |
| Max. Negotiated Rate |
$186.40 |
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Health Management Network Commercial |
$163.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.94
|
| Rate for Payer: MDX Hawaii PPO |
$186.40
|
|
|
amiodarone-D5W 360 mg/200 mL premix [HHSC]
|
Facility
|
OP
|
$293.11
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2500049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$284.32 |
| Rate for Payer: AlohaCare Medicaid |
$146.56
|
| Rate for Payer: AlohaCare Medicare |
$146.56
|
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Devoted Health Medicare |
$161.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$146.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$278.45
|
| Rate for Payer: Health Management Network Commercial |
$249.14
|
| Rate for Payer: Humana Medicare |
$146.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$263.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$149.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$146.56
|
| Rate for Payer: MDX Hawaii PPO |
$284.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$146.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$146.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$175.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$146.56
|
| Rate for Payer: University Health Alliance Commercial |
$213.65
|
|
|
amiodarone-D5W 360 mg/200 mL premix [HHSC]
|
Facility
|
IP
|
$293.11
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2500049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$249.14 |
| Max. Negotiated Rate |
$284.32 |
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Health Management Network Commercial |
$249.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$263.80
|
| Rate for Payer: MDX Hawaii PPO |
$284.32
|
|
|
Amiodarone FSI
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS 80151
|
| Hospital Charge Code |
8228835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.20 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
|
|
Amiodarone FSI
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS 80151
|
| Hospital Charge Code |
8228835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: AlohaCare Medicaid |
$106.00
|
| Rate for Payer: AlohaCare Medicare |
$106.00
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Devoted Health Medicare |
$116.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Humana Medicare |
$106.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.00
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.00
|
| Rate for Payer: University Health Alliance Commercial |
$118.72
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048801
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 67877019890
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Health Management Network Commercial |
$8.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.96
|
| Rate for Payer: MDX Hawaii PPO |
$9.65
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$19.34
|
|
|
Service Code
|
NDC 50268008415
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$18.76 |
| Rate for Payer: Cash Price |
$12.57
|
| Rate for Payer: Health Management Network Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.41
|
| Rate for Payer: MDX Hawaii PPO |
$18.76
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$9.62
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: AlohaCare Medicaid |
$4.81
|
| Rate for Payer: AlohaCare Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Devoted Health Medicare |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.14
|
| Rate for Payer: Health Management Network Commercial |
$8.18
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.81
|
| Rate for Payer: MDX Hawaii PPO |
$9.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.81
|
| Rate for Payer: University Health Alliance Commercial |
$7.01
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$9.62
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Health Management Network Commercial |
$8.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$9.33
|
|
