|
AUTO SUTURE, TA 90 3.5 MM RELOADS
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
8274223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$181.90 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: Cash Price |
$139.10
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
|
|
AUTO SUTURE, TA 90 3.5 MM RELOADS
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
8274223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.00 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: AlohaCare Medicaid |
$107.00
|
| Rate for Payer: AlohaCare Medicare |
$107.00
|
| Rate for Payer: Cash Price |
$139.10
|
| Rate for Payer: Devoted Health Medicare |
$117.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$203.30
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Humana Medicare |
$107.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.00
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.00
|
| Rate for Payer: University Health Alliance Commercial |
$155.98
|
|
|
azithromycin 200 mg/5 ml 30ml [HHSC]
|
Facility
|
IP
|
$163.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.36 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
|
|
azithromycin 200 mg/5 ml 30ml [HHSC]
|
Facility
|
OP
|
$163.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.97 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: AlohaCare Medicaid |
$81.97
|
| Rate for Payer: AlohaCare Medicare |
$81.97
|
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Devoted Health Medicare |
$90.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.75
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Humana Medicare |
$81.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.97
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.97
|
| Rate for Payer: University Health Alliance Commercial |
$91.81
|
|
|
azithromycin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$10.41
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: AlohaCare Medicaid |
$5.21
|
| Rate for Payer: AlohaCare Medicaid |
$11.72
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$5.21
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$5.73
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Devoted Health Medicare |
$12.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$19.92
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$5.21
|
| Rate for Payer: Humana Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$22.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.72
|
| Rate for Payer: University Health Alliance Commercial |
$1.68
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$13.13
|
|
|
azithromycin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$23.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.92 |
| Max. Negotiated Rate |
$22.74 |
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$19.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.74
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
azithromycin 500 mg vial [HHSC]
|
Facility
|
IP
|
$53.12
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
2500089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.15 |
| Max. Negotiated Rate |
$51.53 |
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$45.15
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$16.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: MDX Hawaii PPO |
$51.53
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$18.94
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
|
|
azithromycin 500 mg vial [HHSC]
|
Facility
|
OP
|
$44.74
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
2500089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicaid |
$26.56
|
| Rate for Payer: AlohaCare Medicaid |
$32.06
|
| Rate for Payer: AlohaCare Medicaid |
$9.77
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$26.56
|
| Rate for Payer: AlohaCare Medicare |
$32.06
|
| Rate for Payer: AlohaCare Medicare |
$9.77
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$10.74
|
| Rate for Payer: Devoted Health Medicare |
$29.22
|
| Rate for Payer: Devoted Health Medicare |
$35.27
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.92
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$16.60
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Health Management Network Commercial |
$45.15
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$9.77
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Humana Medicare |
$26.56
|
| Rate for Payer: Humana Medicare |
$32.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.06
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$51.53
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$18.94
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: University Health Alliance Commercial |
$14.24
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$38.72
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$46.74
|
|
|
bacitracin 500 units/gm oint 14gm [HHSC]
|
Facility
|
OP
|
$20.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$19.42 |
| Rate for Payer: AlohaCare Medicaid |
$10.01
|
| Rate for Payer: AlohaCare Medicare |
$10.01
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Devoted Health Medicare |
$11.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.02
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Humana Medicare |
$10.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.01
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.01
|
| Rate for Payer: University Health Alliance Commercial |
$11.21
|
|
|
bacitracin 500 units/gm oint 14gm [HHSC]
|
Facility
|
IP
|
$20.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$19.42 |
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC
|
Facility
|
IP
|
$46,361.11
|
|
|
Service Code
|
MSDRG 519
|
| Min. Negotiated Rate |
$46,361.11 |
| Max. Negotiated Rate |
$46,361.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,361.11
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR
|
Facility
|
IP
|
$46,361.11
|
|
|
Service Code
|
MSDRG 518
|
| Min. Negotiated Rate |
$46,361.11 |
| Max. Negotiated Rate |
$46,361.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,361.11
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$29,911.92
|
|
|
Service Code
|
MSDRG 520
|
| Min. Negotiated Rate |
$29,911.92 |
| Max. Negotiated Rate |
$29,911.92 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29,911.92
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC
|
Facility
|
IP
|
$51,314.83
|
|
|
Service Code
|
MSDRG 095
|
| Min. Negotiated Rate |
$51,314.83 |
| Max. Negotiated Rate |
$51,314.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,314.83
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC
|
Facility
|
IP
|
$51,314.83
|
|
|
Service Code
|
MSDRG 094
|
| Min. Negotiated Rate |
$51,314.83 |
| Max. Negotiated Rate |
$51,314.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,314.83
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$51,314.83
|
|
|
Service Code
|
MSDRG 096
|
| Min. Negotiated Rate |
$51,314.83 |
| Max. Negotiated Rate |
$51,314.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,314.83
|
|
|
BAKRI BALLOON
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
9271650
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$692.00 |
| 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: Devoted Health Medicare |
$761.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,314.80
|
| 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 Medicare |
$692.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,008.80
|
|
|
BAKRI BALLOON
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
9271650
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
BANDAGE TENSOPLAST 2X5YD SUPPORT /COMPRESSION ELST TAN LTX 1/RL, 36 RL/CA
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
12954858
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Devoted Health Medicare |
$1.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.00
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.00
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
BANDAGE TENSOPLAST 2X5YD SUPPORT /COMPRESSION ELST TAN LTX 1/RL, 36 RL/CA
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
12954858
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
BANDAGE TENSOPLAST 2X5YD SUPPORT /COMPRESSION ELST TAN LTX 1/RL, 36 RL/CA
|
Professional
|
Both
|
$2.00
|
|
| Hospital Charge Code |
12954858
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
|
|
.Barbiturates, Ur Cnfrm FSI
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS 80345
|
| Hospital Charge Code |
8728196
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$113.10
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
.Barbiturates, Ur Cnfrm FSI
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
HCPCS 80345
|
| Hospital Charge Code |
8728196
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: AlohaCare Medicaid |
$87.00
|
| Rate for Payer: AlohaCare Medicare |
$87.00
|
| Rate for Payer: Cash Price |
$113.10
|
| Rate for Payer: Cash Price |
$113.10
|
| Rate for Payer: Devoted Health Medicare |
$95.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.30
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Humana Medicare |
$87.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.00
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.00
|
| Rate for Payer: University Health Alliance Commercial |
$97.44
|
|
|
Barbiturates, Urine Screen FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228839
|
|
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
|
|
|
Barbiturates, Urine Screen FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228839
|
|
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
|
|
