|
Closed Elbow Dis W/o Anes TechFee
|
Facility
|
IP
|
$823.00
|
|
|
Service Code
|
HCPCS 24600
|
| Hospital Charge Code |
8022932
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$699.55 |
| Max. Negotiated Rate |
$798.31 |
| Rate for Payer: Cash Price |
$534.95
|
| Rate for Payer: Health Management Network Commercial |
$699.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$740.70
|
| Rate for Payer: MDX Hawaii PPO |
$798.31
|
|
|
CLOSED TRACHEAL SUCTION CHARGE
|
Facility
|
OP
|
$85.00
|
|
| Hospital Charge Code |
8243409
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$82.45 |
| Rate for Payer: AlohaCare Medicaid |
$42.50
|
| Rate for Payer: AlohaCare Medicare |
$42.50
|
| Rate for Payer: Cash Price |
$55.25
|
| Rate for Payer: Devoted Health Medicare |
$46.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$80.75
|
| Rate for Payer: Health Management Network Commercial |
$72.25
|
| Rate for Payer: Humana Medicare |
$42.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.50
|
| Rate for Payer: MDX Hawaii PPO |
$82.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.50
|
| Rate for Payer: University Health Alliance Commercial |
$61.96
|
|
|
CLOSED TRACHEAL SUCTION CHARGE
|
Facility
|
IP
|
$85.00
|
|
| Hospital Charge Code |
8243409
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$72.25 |
| Max. Negotiated Rate |
$82.45 |
| Rate for Payer: Cash Price |
$55.25
|
| Rate for Payer: Health Management Network Commercial |
$72.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.50
|
| Rate for Payer: MDX Hawaii PPO |
$82.45
|
|
|
Clostridium Difficile Antigen/Toxin Antibody Reflex PCR FSI
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
8117884
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$86.50
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Devoted Health Medicare |
$95.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.98
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$86.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.50
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.01
|
|
|
Clostridium Difficile Antigen/Toxin Antibody Reflex PCR FSI
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 87324
|
| Hospital Charge Code |
8117884
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$112.45
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
Clostridium Difficile PCR FSI
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
8117885
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: AlohaCare Medicaid |
$138.00
|
| Rate for Payer: AlohaCare Medicare |
$138.00
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Devoted Health Medicare |
$151.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.59
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$138.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Humana Medicare |
$138.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$140.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$138.00
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$138.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$138.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$138.00
|
| Rate for Payer: University Health Alliance Commercial |
$31.04
|
|
|
Clostridium Difficile PCR FSI
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
8117885
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$234.60 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
OP
|
$52.40
|
|
|
Service Code
|
NDC 00904782231
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.20 |
| Max. Negotiated Rate |
$50.83 |
| Rate for Payer: AlohaCare Medicaid |
$26.20
|
| Rate for Payer: AlohaCare Medicare |
$26.20
|
| Rate for Payer: Cash Price |
$34.06
|
| Rate for Payer: Devoted Health Medicare |
$28.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.78
|
| Rate for Payer: Health Management Network Commercial |
$44.54
|
| Rate for Payer: Humana Medicare |
$26.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.20
|
| Rate for Payer: MDX Hawaii PPO |
$50.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.20
|
| Rate for Payer: University Health Alliance Commercial |
$38.19
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
IP
|
$50.78
|
|
|
Service Code
|
NDC 24385020503
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$49.26 |
| Rate for Payer: Cash Price |
$33.01
|
| Rate for Payer: Health Management Network Commercial |
$43.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.70
|
| Rate for Payer: MDX Hawaii PPO |
$49.26
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
OP
|
$64.13
|
|
|
Service Code
|
NDC 51672200202
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$62.21 |
| Rate for Payer: AlohaCare Medicaid |
$32.06
|
| Rate for Payer: AlohaCare Medicare |
$32.06
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Devoted Health Medicare |
$35.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.92
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Humana Medicare |
$32.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.06
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.06
|
| Rate for Payer: University Health Alliance Commercial |
$46.74
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
IP
|
$54.50
|
|
|
Service Code
|
NDC 68001047547
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.33 |
| Max. Negotiated Rate |
$52.87 |
| Rate for Payer: Cash Price |
$35.43
|
| Rate for Payer: Health Management Network Commercial |
$46.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.05
|
| Rate for Payer: MDX Hawaii PPO |
$52.87
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
OP
|
$50.78
|
|
|
Service Code
|
NDC 24385020503
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.39 |
| Max. Negotiated Rate |
$49.26 |
| Rate for Payer: AlohaCare Medicaid |
$25.39
|
| Rate for Payer: AlohaCare Medicare |
$25.39
|
| Rate for Payer: Cash Price |
$33.01
|
| Rate for Payer: Devoted Health Medicare |
$27.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.24
|
| Rate for Payer: Health Management Network Commercial |
$43.16
|
| Rate for Payer: Humana Medicare |
$25.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.39
|
| Rate for Payer: MDX Hawaii PPO |
$49.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.39
|
| Rate for Payer: University Health Alliance Commercial |
$37.01
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
IP
|
$51.51
|
|
|
Service Code
|
NDC 45802043411
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.78 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Health Management Network Commercial |
$43.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.36
|
| Rate for Payer: MDX Hawaii PPO |
$49.96
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
OP
|
$51.51
|
|
|
Service Code
|
NDC 45802043411
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$49.96 |
| Rate for Payer: AlohaCare Medicaid |
$25.75
|
| Rate for Payer: AlohaCare Medicare |
$25.75
|
| Rate for Payer: Cash Price |
$33.48
|
| Rate for Payer: Devoted Health Medicare |
$28.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.93
|
| Rate for Payer: Health Management Network Commercial |
$43.78
|
| Rate for Payer: Humana Medicare |
$25.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.75
|
| Rate for Payer: MDX Hawaii PPO |
$49.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.75
|
| Rate for Payer: University Health Alliance Commercial |
$37.55
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
IP
|
$64.13
|
|
|
Service Code
|
NDC 51672200202
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.51 |
| Max. Negotiated Rate |
$62.21 |
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
IP
|
$52.40
|
|
|
Service Code
|
NDC 00904782231
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.54 |
| Max. Negotiated Rate |
$50.83 |
| Rate for Payer: Cash Price |
$34.06
|
| Rate for Payer: Health Management Network Commercial |
$44.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.16
|
| Rate for Payer: MDX Hawaii PPO |
$50.83
|
|
|
clotrimazole 1% cream topical [HHSC]
|
Facility
|
OP
|
$54.50
|
|
|
Service Code
|
NDC 68001047547
|
| Hospital Charge Code |
2500197
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.25 |
| Max. Negotiated Rate |
$52.87 |
| Rate for Payer: AlohaCare Medicaid |
$27.25
|
| Rate for Payer: AlohaCare Medicare |
$27.25
|
| Rate for Payer: Cash Price |
$35.43
|
| Rate for Payer: Devoted Health Medicare |
$29.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.77
|
| Rate for Payer: Health Management Network Commercial |
$46.33
|
| Rate for Payer: Humana Medicare |
$27.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.25
|
| Rate for Payer: MDX Hawaii PPO |
$52.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.25
|
| Rate for Payer: University Health Alliance Commercial |
$39.73
|
|
|
cloZAPine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$18.64 |
| Rate for Payer: AlohaCare Medicaid |
$9.61
|
| Rate for Payer: AlohaCare Medicaid |
$9.25
|
| Rate for Payer: AlohaCare Medicaid |
$9.53
|
| Rate for Payer: AlohaCare Medicare |
$9.25
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: AlohaCare Medicare |
$9.53
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Cash Price |
$12.02
|
| Rate for Payer: Cash Price |
$12.49
|
| Rate for Payer: Devoted Health Medicare |
$10.48
|
| Rate for Payer: Devoted Health Medicare |
$10.18
|
| Rate for Payer: Devoted Health Medicare |
$10.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.57
|
| Rate for Payer: Health Management Network Commercial |
$15.72
|
| Rate for Payer: Health Management Network Commercial |
$16.34
|
| Rate for Payer: Health Management Network Commercial |
$16.20
|
| Rate for Payer: Humana Medicare |
$9.25
|
| Rate for Payer: Humana Medicare |
$9.53
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.53
|
| Rate for Payer: MDX Hawaii PPO |
$18.64
|
| Rate for Payer: MDX Hawaii PPO |
$18.49
|
| Rate for Payer: MDX Hawaii PPO |
$17.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.25
|
| Rate for Payer: University Health Alliance Commercial |
$10.76
|
| Rate for Payer: University Health Alliance Commercial |
$10.36
|
| Rate for Payer: University Health Alliance Commercial |
$10.67
|
|
|
cloZAPine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$19.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500198
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.34 |
| Max. Negotiated Rate |
$18.64 |
| Rate for Payer: Cash Price |
$12.49
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Cash Price |
$12.02
|
| Rate for Payer: Health Management Network Commercial |
$16.34
|
| Rate for Payer: Health Management Network Commercial |
$15.72
|
| Rate for Payer: Health Management Network Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.30
|
| Rate for Payer: MDX Hawaii PPO |
$18.49
|
| Rate for Payer: MDX Hawaii PPO |
$17.95
|
| Rate for Payer: MDX Hawaii PPO |
$18.64
|
|
|
cloZAPine 25 mg tablet [HHSC]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500199
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$6.98 |
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$6.12
|
| Rate for Payer: Health Management Network Commercial |
$6.26
|
| Rate for Payer: Health Management Network Commercial |
$6.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.65
|
| Rate for Payer: MDX Hawaii PPO |
$6.98
|
| Rate for Payer: MDX Hawaii PPO |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$7.17
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
cloZAPine 25 mg tablet [HHSC]
|
Facility
|
OP
|
$7.39
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500199
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$7.17 |
| Rate for Payer: AlohaCare Medicaid |
$3.69
|
| Rate for Payer: AlohaCare Medicaid |
$3.68
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicaid |
$3.60
|
| Rate for Payer: AlohaCare Medicare |
$3.60
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$3.69
|
| Rate for Payer: AlohaCare Medicare |
$3.68
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$3.96
|
| Rate for Payer: Devoted Health Medicare |
$4.06
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Devoted Health Medicare |
$4.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network Commercial |
$6.12
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$6.26
|
| Rate for Payer: Health Management Network Commercial |
$6.28
|
| Rate for Payer: Humana Medicare |
$3.68
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$3.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.69
|
| Rate for Payer: MDX Hawaii PPO |
$6.98
|
| Rate for Payer: MDX Hawaii PPO |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$7.17
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$4.12
|
| Rate for Payer: University Health Alliance Commercial |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$4.14
|
| Rate for Payer: University Health Alliance Commercial |
$1.68
|
|
|
Clozapine FSI
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
8228857
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$199.82 |
| Rate for Payer: AlohaCare Medicaid |
$103.00
|
| Rate for Payer: AlohaCare Medicare |
$103.00
|
| Rate for Payer: Cash Price |
$133.90
|
| Rate for Payer: Cash Price |
$133.90
|
| Rate for Payer: Devoted Health Medicare |
$113.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$30.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.11
|
| Rate for Payer: Health Management Network Commercial |
$175.10
|
| Rate for Payer: Humana Medicare |
$103.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$185.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.00
|
| Rate for Payer: MDX Hawaii PPO |
$199.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.00
|
| Rate for Payer: University Health Alliance Commercial |
$46.68
|
|
|
Clozapine FSI
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 83789
|
| Hospital Charge Code |
8228857
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$175.10 |
| Max. Negotiated Rate |
$199.82 |
| Rate for Payer: Cash Price |
$133.90
|
| Rate for Payer: Health Management Network Commercial |
$175.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$185.40
|
| Rate for Payer: MDX Hawaii PPO |
$199.82
|
|
|
COAGULATION DISORDERS
|
Facility
|
IP
|
$32,258.42
|
|
|
Service Code
|
MSDRG 813
|
| Min. Negotiated Rate |
$32,258.42 |
| Max. Negotiated Rate |
$32,258.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,258.42
|
|
|
Cocaine, Urine Screen FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228858
|
|
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
|
|
