|
DEMO EVAL INH NEB USE CHARGE
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS 94664
|
| Hospital Charge Code |
8243402
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$14.35 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: AlohaCare Medicaid |
$131.00
|
| Rate for Payer: AlohaCare Medicare |
$131.00
|
| Rate for Payer: Cash Price |
$170.30
|
| Rate for Payer: Cash Price |
$170.30
|
| Rate for Payer: Devoted Health Medicare |
$144.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$279.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$248.90
|
| Rate for Payer: Health Management Network Commercial |
$222.70
|
| Rate for Payer: Humana Medicare |
$131.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$235.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$133.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.00
|
| Rate for Payer: MDX Hawaii PPO |
$254.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.00
|
| Rate for Payer: University Health Alliance Commercial |
$146.72
|
|
|
DEMO EVAL INH NEB USE CHARGE
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS 94664
|
| Hospital Charge Code |
8243402
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$222.70 |
| Max. Negotiated Rate |
$254.14 |
| Rate for Payer: Cash Price |
$170.30
|
| Rate for Payer: Health Management Network Commercial |
$222.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$235.80
|
| Rate for Payer: MDX Hawaii PPO |
$254.14
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$19,933.38
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$19,933.38 |
| Max. Negotiated Rate |
$19,933.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,933.38
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$19,933.38
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$19,933.38 |
| Max. Negotiated Rate |
$19,933.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,933.38
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,933.38
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$19,933.38 |
| Max. Negotiated Rate |
$19,933.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,933.38
|
|
|
Depression Screening
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
739763
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$5.16
|
| Rate for Payer: AlohaCare Medicare |
$5.51
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Devoted Health Medicare |
$6.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.04
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$10,002.24
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$10,002.24 |
| Max. Negotiated Rate |
$10,002.24 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,002.24
|
|
|
DERMABOND ADVANCED PEN DNX12
|
Facility
|
OP
|
$127.00
|
|
| Hospital Charge Code |
12912337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.65
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$92.57
|
|
|
DERMABOND ADVANCED PEN DNX12
|
Facility
|
IP
|
$127.00
|
|
| Hospital Charge Code |
12912337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
desmopressin 4 mcg/1ml ampule [HHSC]
|
Facility
|
OP
|
$177.40
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
2500219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$172.08 |
| Rate for Payer: AlohaCare Medicaid |
$88.70
|
| Rate for Payer: AlohaCare Medicaid |
$172.97
|
| Rate for Payer: AlohaCare Medicare |
$172.97
|
| Rate for Payer: AlohaCare Medicare |
$88.70
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Devoted Health Medicare |
$97.57
|
| Rate for Payer: Devoted Health Medicare |
$190.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$328.65
|
| Rate for Payer: Health Management Network Commercial |
$294.06
|
| Rate for Payer: Health Management Network Commercial |
$150.79
|
| Rate for Payer: Humana Medicare |
$88.70
|
| Rate for Payer: Humana Medicare |
$172.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$176.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.97
|
| Rate for Payer: MDX Hawaii PPO |
$172.08
|
| Rate for Payer: MDX Hawaii PPO |
$335.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$106.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.97
|
| Rate for Payer: University Health Alliance Commercial |
$129.31
|
| Rate for Payer: University Health Alliance Commercial |
$252.16
|
|
|
desmopressin 4 mcg/1ml ampule [HHSC]
|
Facility
|
IP
|
$177.40
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
2500219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.79 |
| Max. Negotiated Rate |
$172.08 |
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Health Management Network Commercial |
$150.79
|
| Rate for Payer: Health Management Network Commercial |
$294.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.36
|
| Rate for Payer: MDX Hawaii PPO |
$335.57
|
| Rate for Payer: MDX Hawaii PPO |
$172.08
|
|
|
dexamethasone 10 mg/1ml vial [HHSC]
|
Facility
|
IP
|
$8.67
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$8.41 |
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Health Management Network Commercial |
$7.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.80
|
| Rate for Payer: MDX Hawaii PPO |
$8.41
|
|
|
dexamethasone 10 mg/1ml vial [HHSC]
|
Facility
|
OP
|
$8.67
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$8.41 |
| Rate for Payer: AlohaCare Medicaid |
$4.33
|
| Rate for Payer: AlohaCare Medicare |
$4.33
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Devoted Health Medicare |
$4.77
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.24
|
| Rate for Payer: Health Management Network Commercial |
$7.37
|
| Rate for Payer: Humana Medicare |
$4.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.33
|
| Rate for Payer: MDX Hawaii PPO |
$8.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.33
|
| Rate for Payer: University Health Alliance Commercial |
$6.32
|
|
|
dexamethasone 4 mg/ml vial [HHSC]
|
Facility
|
OP
|
$4.99
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$2.59
|
| Rate for Payer: AlohaCare Medicaid |
$7.34
|
| Rate for Payer: AlohaCare Medicare |
$2.59
|
| Rate for Payer: AlohaCare Medicare |
$7.34
|
| Rate for Payer: AlohaCare Medicare |
$2.50
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Devoted Health Medicare |
$2.85
|
| Rate for Payer: Devoted Health Medicare |
$2.74
|
| Rate for Payer: Devoted Health Medicare |
$8.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.74
|
| Rate for Payer: Health Management Network Commercial |
$12.48
|
| Rate for Payer: Health Management Network Commercial |
$4.24
|
| Rate for Payer: Health Management Network Commercial |
$4.40
|
| Rate for Payer: Humana Medicare |
$2.50
|
| Rate for Payer: Humana Medicare |
$7.34
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.59
|
| Rate for Payer: MDX Hawaii PPO |
$5.02
|
| Rate for Payer: MDX Hawaii PPO |
$14.24
|
| Rate for Payer: MDX Hawaii PPO |
$4.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.50
|
| Rate for Payer: University Health Alliance Commercial |
$3.78
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$10.70
|
|
|
dexamethasone 4 mg/ml vial [HHSC]
|
Facility
|
IP
|
$14.68
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Management Network Commercial |
$4.40
|
| Rate for Payer: Health Management Network Commercial |
$12.48
|
| Rate for Payer: Health Management Network Commercial |
$4.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.66
|
| Rate for Payer: MDX Hawaii PPO |
$5.02
|
| Rate for Payer: MDX Hawaii PPO |
$14.24
|
| Rate for Payer: MDX Hawaii PPO |
$4.84
|
|
|
dextrose 10%-water 500 ml [HHSC]
|
Facility
|
IP
|
$13.01
|
|
|
Service Code
|
NDC 00264752010
|
| Hospital Charge Code |
2500228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Health Management Network Commercial |
$11.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.71
|
| Rate for Payer: MDX Hawaii PPO |
$12.62
|
|
|
dextrose 10%-water 500 ml [HHSC]
|
Facility
|
OP
|
$13.01
|
|
|
Service Code
|
NDC 00264752010
|
| Hospital Charge Code |
2500228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Devoted Health Medicare |
$7.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.36
|
| Rate for Payer: Health Management Network Commercial |
$11.06
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.50
|
| Rate for Payer: MDX Hawaii PPO |
$12.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
dextrose 40% gel oral [HHSC]
|
Facility
|
IP
|
$21.96
|
|
|
Service Code
|
NDC 00574007030
|
| Hospital Charge Code |
2500359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$21.30 |
| Rate for Payer: Cash Price |
$14.27
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$21.30
|
|
|
dextrose 40% gel oral [HHSC]
|
Facility
|
OP
|
$21.96
|
|
|
Service Code
|
NDC 00574007030
|
| Hospital Charge Code |
2500359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$21.30 |
| Rate for Payer: AlohaCare Medicaid |
$10.98
|
| Rate for Payer: AlohaCare Medicare |
$10.98
|
| Rate for Payer: Cash Price |
$14.27
|
| 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 |
$20.86
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Humana Medicare |
$10.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.98
|
| Rate for Payer: MDX Hawaii PPO |
$21.30
|
| 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
|
|
|
dextrose 40% gel oral [HHSC]
|
Facility
|
IP
|
$21.96
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
2500359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$21.30 |
| Rate for Payer: Cash Price |
$14.27
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$21.30
|
|
|
dextrose 40% gel oral [HHSC]
|
Facility
|
OP
|
$21.96
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
2500359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$21.30 |
| Rate for Payer: AlohaCare Medicaid |
$10.98
|
| Rate for Payer: AlohaCare Medicare |
$10.98
|
| Rate for Payer: Cash Price |
$14.27
|
| 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 |
$20.86
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Humana Medicare |
$10.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.98
|
| Rate for Payer: MDX Hawaii PPO |
$21.30
|
| 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
|
|
|
dextrose 50%-water 50ml syringe [HHSC]
|
Facility
|
IP
|
$110.11
|
|
|
Service Code
|
NDC 00409490234
|
| Hospital Charge Code |
2500360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$106.81 |
| Rate for Payer: Cash Price |
$71.57
|
| Rate for Payer: Health Management Network Commercial |
$93.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.10
|
| Rate for Payer: MDX Hawaii PPO |
$106.81
|
|
|
dextrose 50%-water 50ml syringe [HHSC]
|
Facility
|
IP
|
$119.67
|
|
|
Service Code
|
NDC 76329330201
|
| Hospital Charge Code |
2500360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.72 |
| Max. Negotiated Rate |
$116.08 |
| Rate for Payer: Cash Price |
$77.79
|
| Rate for Payer: Health Management Network Commercial |
$101.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.70
|
| Rate for Payer: MDX Hawaii PPO |
$116.08
|
|
|
dextrose 50%-water 50ml syringe [HHSC]
|
Facility
|
OP
|
$68.31
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
2500360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.16 |
| Max. Negotiated Rate |
$66.26 |
| Rate for Payer: AlohaCare Medicaid |
$34.16
|
| Rate for Payer: AlohaCare Medicare |
$34.16
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$37.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.89
|
| Rate for Payer: Health Management Network Commercial |
$58.06
|
| Rate for Payer: Humana Medicare |
$34.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.16
|
| Rate for Payer: MDX Hawaii PPO |
$66.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.16
|
| Rate for Payer: University Health Alliance Commercial |
$49.79
|
|
|
dextrose 50%-water 50ml syringe [HHSC]
|
Facility
|
IP
|
$68.31
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
2500360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.06 |
| Max. Negotiated Rate |
$66.26 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$58.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.48
|
| Rate for Payer: MDX Hawaii PPO |
$66.26
|
|
