|
amoxicillin-clav 875 mg tablet [HHSC]
|
Facility
|
OP
|
$28.09
|
|
|
Service Code
|
NDC 65862050320
|
| Hospital Charge Code |
2500058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$27.25 |
| Rate for Payer: AlohaCare Medicaid |
$14.04
|
| Rate for Payer: AlohaCare Medicare |
$14.04
|
| Rate for Payer: Cash Price |
$18.26
|
| Rate for Payer: Devoted Health Medicare |
$15.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.69
|
| Rate for Payer: Health Management Network Commercial |
$23.88
|
| Rate for Payer: Humana Medicare |
$14.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.04
|
| Rate for Payer: MDX Hawaii PPO |
$27.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.04
|
| Rate for Payer: University Health Alliance Commercial |
$20.47
|
|
|
amoxicillin-clav 875 mg tablet [HHSC]
|
Facility
|
IP
|
$28.09
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
2500058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$27.25 |
| Rate for Payer: Cash Price |
$18.26
|
| Rate for Payer: Health Management Network Commercial |
$23.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.25
|
|
|
amoxicillin-clav 875 mg tablet [HHSC]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
2500058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: AlohaCare Medicaid |
$5.63
|
| Rate for Payer: AlohaCare Medicare |
$5.63
|
| Rate for Payer: Cash Price |
$7.32
|
| Rate for Payer: Devoted Health Medicare |
$6.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.70
|
| Rate for Payer: Health Management Network Commercial |
$9.57
|
| Rate for Payer: Humana Medicare |
$5.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.63
|
| Rate for Payer: MDX Hawaii PPO |
$10.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.63
|
| Rate for Payer: University Health Alliance Commercial |
$8.21
|
|
|
amoxicillin-clav 875 mg tablet [HHSC]
|
Facility
|
IP
|
$28.09
|
|
|
Service Code
|
NDC 65862050320
|
| Hospital Charge Code |
2500058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$27.25 |
| Rate for Payer: Cash Price |
$18.26
|
| Rate for Payer: Health Management Network Commercial |
$23.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.25
|
|
|
Amphetamines, Urine Screen FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1,176.40 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
|
|
Amphetamines, Urine Screen FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: AlohaCare Medicaid |
$692.00
|
| Rate for Payer: AlohaCare Medicare |
$692.00
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Devoted Health Medicare |
$761.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$77.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.14
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Humana Medicare |
$692.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$705.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$692.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$692.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$692.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$692.00
|
| Rate for Payer: University Health Alliance Commercial |
$147.65
|
|
|
Amphetamine Ur Confirm FSI
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8228836
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$228.92 |
| Rate for Payer: Cash Price |
$153.40
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
|
|
Amphetamine Ur Confirm FSI
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8228836
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$228.92 |
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
| Rate for Payer: AlohaCare Medicaid |
$118.00
|
| Rate for Payer: AlohaCare Medicare |
$118.00
|
| Rate for Payer: Cash Price |
$153.40
|
| Rate for Payer: Cash Price |
$153.40
|
| Rate for Payer: Devoted Health Medicare |
$129.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$143.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$224.20
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Humana Medicare |
$118.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.00
|
| Rate for Payer: University Health Alliance Commercial |
$132.16
|
|
|
ampicillin 2 gm vial [HHSC]
|
Facility
|
IP
|
$84.67
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
2500060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.97 |
| Max. Negotiated Rate |
$82.13 |
| Rate for Payer: Cash Price |
$55.04
|
| Rate for Payer: Cash Price |
$57.44
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$57.32
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Health Management Network Commercial |
$75.11
|
| Rate for Payer: Health Management Network Commercial |
$71.97
|
| Rate for Payer: Health Management Network Commercial |
$74.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.72
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
| Rate for Payer: MDX Hawaii PPO |
$82.13
|
| Rate for Payer: MDX Hawaii PPO |
$85.53
|
|
|
ampicillin 2 gm vial [HHSC]
|
Facility
|
OP
|
$84.67
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
2500060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$82.13 |
| Rate for Payer: AlohaCare Medicaid |
$42.34
|
| Rate for Payer: AlohaCare Medicaid |
$44.09
|
| Rate for Payer: AlohaCare Medicaid |
$36.66
|
| Rate for Payer: AlohaCare Medicaid |
$44.19
|
| Rate for Payer: AlohaCare Medicare |
$44.19
|
| Rate for Payer: AlohaCare Medicare |
$36.66
|
| Rate for Payer: AlohaCare Medicare |
$42.34
|
| Rate for Payer: AlohaCare Medicare |
$44.09
|
| Rate for Payer: Cash Price |
$57.44
|
| Rate for Payer: Cash Price |
$55.04
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$57.44
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$57.32
|
| Rate for Payer: Cash Price |
$55.04
|
| Rate for Payer: Cash Price |
$57.32
|
| Rate for Payer: Devoted Health Medicare |
$48.50
|
| Rate for Payer: Devoted Health Medicare |
$46.57
|
| Rate for Payer: Devoted Health Medicare |
$48.60
|
| Rate for Payer: Devoted Health Medicare |
$40.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$80.44
|
| Rate for Payer: Health Management Network Commercial |
$74.95
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Health Management Network Commercial |
$71.97
|
| Rate for Payer: Health Management Network Commercial |
$75.11
|
| Rate for Payer: Humana Medicare |
$36.66
|
| Rate for Payer: Humana Medicare |
$44.09
|
| Rate for Payer: Humana Medicare |
$42.34
|
| Rate for Payer: Humana Medicare |
$44.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.34
|
| Rate for Payer: MDX Hawaii PPO |
$85.53
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
| Rate for Payer: MDX Hawaii PPO |
$85.72
|
| Rate for Payer: MDX Hawaii PPO |
$82.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.34
|
| Rate for Payer: University Health Alliance Commercial |
$53.45
|
| Rate for Payer: University Health Alliance Commercial |
$61.72
|
| Rate for Payer: University Health Alliance Commercial |
$64.27
|
| Rate for Payer: University Health Alliance Commercial |
$64.41
|
|
|
ampicillin-sulbactam 3gm vial [HHSC]
|
Facility
|
OP
|
$98.16
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
2500063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$95.22 |
| Rate for Payer: AlohaCare Medicaid |
$49.08
|
| Rate for Payer: AlohaCare Medicaid |
$20.32
|
| Rate for Payer: AlohaCare Medicaid |
$28.71
|
| Rate for Payer: AlohaCare Medicaid |
$39.59
|
| Rate for Payer: AlohaCare Medicaid |
$23.39
|
| Rate for Payer: AlohaCare Medicaid |
$12.81
|
| Rate for Payer: AlohaCare Medicaid |
$29.68
|
| Rate for Payer: AlohaCare Medicaid |
$41.20
|
| Rate for Payer: AlohaCare Medicaid |
$45.05
|
| Rate for Payer: AlohaCare Medicare |
$49.08
|
| Rate for Payer: AlohaCare Medicare |
$39.59
|
| Rate for Payer: AlohaCare Medicare |
$23.39
|
| Rate for Payer: AlohaCare Medicare |
$12.81
|
| Rate for Payer: AlohaCare Medicare |
$20.32
|
| Rate for Payer: AlohaCare Medicare |
$41.20
|
| Rate for Payer: AlohaCare Medicare |
$45.05
|
| Rate for Payer: AlohaCare Medicare |
$28.71
|
| Rate for Payer: AlohaCare Medicare |
$29.68
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$58.57
|
| Rate for Payer: Cash Price |
$53.56
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$37.33
|
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$30.41
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Cash Price |
$30.41
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$51.47
|
| Rate for Payer: Cash Price |
$53.56
|
| Rate for Payer: Cash Price |
$51.47
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$37.33
|
| Rate for Payer: Cash Price |
$58.57
|
| Rate for Payer: Devoted Health Medicare |
$32.64
|
| Rate for Payer: Devoted Health Medicare |
$45.32
|
| Rate for Payer: Devoted Health Medicare |
$53.99
|
| Rate for Payer: Devoted Health Medicare |
$49.56
|
| Rate for Payer: Devoted Health Medicare |
$22.36
|
| Rate for Payer: Devoted Health Medicare |
$31.59
|
| Rate for Payer: Devoted Health Medicare |
$25.73
|
| Rate for Payer: Devoted Health Medicare |
$43.55
|
| Rate for Payer: Devoted Health Medicare |
$14.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.28
|
| Rate for Payer: Health Management Network Commercial |
$67.30
|
| Rate for Payer: Health Management Network Commercial |
$34.55
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Health Management Network Commercial |
$83.44
|
| Rate for Payer: Health Management Network Commercial |
$48.82
|
| Rate for Payer: Health Management Network Commercial |
$39.77
|
| Rate for Payer: Health Management Network Commercial |
$76.59
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Health Management Network Commercial |
$70.04
|
| Rate for Payer: Humana Medicare |
$29.68
|
| Rate for Payer: Humana Medicare |
$20.32
|
| Rate for Payer: Humana Medicare |
$12.81
|
| Rate for Payer: Humana Medicare |
$23.39
|
| Rate for Payer: Humana Medicare |
$28.71
|
| Rate for Payer: Humana Medicare |
$39.59
|
| Rate for Payer: Humana Medicare |
$41.20
|
| Rate for Payer: Humana Medicare |
$45.05
|
| Rate for Payer: Humana Medicare |
$49.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.05
|
| Rate for Payer: MDX Hawaii PPO |
$87.41
|
| Rate for Payer: MDX Hawaii PPO |
$55.71
|
| Rate for Payer: MDX Hawaii PPO |
$76.80
|
| Rate for Payer: MDX Hawaii PPO |
$95.22
|
| Rate for Payer: MDX Hawaii PPO |
$79.93
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
| Rate for Payer: MDX Hawaii PPO |
$45.39
|
| Rate for Payer: MDX Hawaii PPO |
$39.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.05
|
| Rate for Payer: University Health Alliance Commercial |
$71.55
|
| Rate for Payer: University Health Alliance Commercial |
$65.68
|
| Rate for Payer: University Health Alliance Commercial |
$60.06
|
| Rate for Payer: University Health Alliance Commercial |
$34.11
|
| Rate for Payer: University Health Alliance Commercial |
$29.63
|
| Rate for Payer: University Health Alliance Commercial |
$18.67
|
| Rate for Payer: University Health Alliance Commercial |
$57.71
|
| Rate for Payer: University Health Alliance Commercial |
$41.86
|
| Rate for Payer: University Health Alliance Commercial |
$43.26
|
|
|
ampicillin-sulbactam 3gm vial [HHSC]
|
Facility
|
IP
|
$82.40
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
2500063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.04 |
| Max. Negotiated Rate |
$79.93 |
| Rate for Payer: Cash Price |
$53.56
|
| Rate for Payer: Cash Price |
$51.47
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$37.33
|
| Rate for Payer: Cash Price |
$30.41
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Cash Price |
$58.57
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Health Management Network Commercial |
$70.04
|
| Rate for Payer: Health Management Network Commercial |
$67.30
|
| Rate for Payer: Health Management Network Commercial |
$34.55
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Health Management Network Commercial |
$39.77
|
| Rate for Payer: Health Management Network Commercial |
$83.44
|
| Rate for Payer: Health Management Network Commercial |
$76.59
|
| Rate for Payer: Health Management Network Commercial |
$48.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.34
|
| Rate for Payer: MDX Hawaii PPO |
$79.93
|
| Rate for Payer: MDX Hawaii PPO |
$55.71
|
| Rate for Payer: MDX Hawaii PPO |
$45.39
|
| Rate for Payer: MDX Hawaii PPO |
$95.22
|
| Rate for Payer: MDX Hawaii PPO |
$87.41
|
| Rate for Payer: MDX Hawaii PPO |
$39.43
|
| Rate for Payer: MDX Hawaii PPO |
$76.80
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
|
IP
|
$80,800.12
|
|
|
Service Code
|
MSDRG 240
|
| Min. Negotiated Rate |
$80,800.12 |
| Max. Negotiated Rate |
$80,800.12 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80,800.12
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC
|
Facility
|
IP
|
$80,800.12
|
|
|
Service Code
|
MSDRG 239
|
| Min. Negotiated Rate |
$80,800.12 |
| Max. Negotiated Rate |
$80,800.12 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80,800.12
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC
|
Facility
|
IP
|
$80,800.12
|
|
|
Service Code
|
MSDRG 241
|
| Min. Negotiated Rate |
$80,800.12 |
| Max. Negotiated Rate |
$80,800.12 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80,800.12
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$40,696.33
|
|
|
Service Code
|
MSDRG 475
|
| Min. Negotiated Rate |
$40,696.33 |
| Max. Negotiated Rate |
$40,696.33 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$40,696.33
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$40,696.33
|
|
|
Service Code
|
MSDRG 474
|
| Min. Negotiated Rate |
$40,696.33 |
| Max. Negotiated Rate |
$40,696.33 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$40,696.33
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$40,696.33
|
|
|
Service Code
|
MSDRG 476
|
| Min. Negotiated Rate |
$40,696.33 |
| Max. Negotiated Rate |
$40,696.33 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$40,696.33
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$71,603.74
|
|
|
Service Code
|
MSDRG 617
|
| Min. Negotiated Rate |
$71,603.74 |
| Max. Negotiated Rate |
$71,603.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,603.74
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$71,603.74
|
|
|
Service Code
|
MSDRG 616
|
| Min. Negotiated Rate |
$71,603.74 |
| Max. Negotiated Rate |
$71,603.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,603.74
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$71,603.74
|
|
|
Service Code
|
MSDRG 618
|
| Min. Negotiated Rate |
$71,603.74 |
| Max. Negotiated Rate |
$71,603.74 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,603.74
|
|
|
Amylase, Fluid FSI
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 82150
|
| Hospital Charge Code |
8404520
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
Amylase, Fluid FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 82150
|
| Hospital Charge Code |
8404520
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.48
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
|
Amylase FSI
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 82150
|
| Hospital Charge Code |
8117839
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
Amylase FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 82150
|
| Hospital Charge Code |
8117839
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.48
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
