|
DLS SARS CoV-2 (COVID-19) RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8873072
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
DLS SARS CoV-2 (COVID-19) RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8873072
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
DMEK TISSUE
|
Facility
|
IP
|
$11,350.00
|
|
|
Service Code
|
HCPCS V2785
|
| Hospital Charge Code |
13156384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,356.00 |
| Max. Negotiated Rate |
$11,009.50 |
| Rate for Payer: Cash Price |
$7,377.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,945.00
|
| Rate for Payer: Health Management Network Commercial |
$9,647.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,215.00
|
| Rate for Payer: MDX Hawaii PPO |
$11,009.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,356.00
|
|
|
DMEK TISSUE
|
Facility
|
OP
|
$11,350.00
|
|
|
Service Code
|
HCPCS V2785
|
| Hospital Charge Code |
13156384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,675.00 |
| Max. Negotiated Rate |
$11,009.50 |
| Rate for Payer: AlohaCare Medicaid |
$5,675.00
|
| Rate for Payer: AlohaCare Medicare |
$5,675.00
|
| Rate for Payer: Cash Price |
$7,377.50
|
| Rate for Payer: Devoted Health Medicare |
$6,242.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,675.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,945.00
|
| Rate for Payer: Health Management Network Commercial |
$9,647.50
|
| Rate for Payer: Humana Medicare |
$5,675.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,215.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,788.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,675.00
|
| Rate for Payer: MDX Hawaii PPO |
$11,009.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,675.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,675.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,675.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,356.00
|
|
|
DOBUTamine 250 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$39.79
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$38.60 |
| Rate for Payer: AlohaCare Medicaid |
$19.89
|
| Rate for Payer: AlohaCare Medicaid |
$27.11
|
| Rate for Payer: AlohaCare Medicaid |
$21.05
|
| Rate for Payer: AlohaCare Medicare |
$21.05
|
| Rate for Payer: AlohaCare Medicare |
$19.89
|
| Rate for Payer: AlohaCare Medicare |
$27.11
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Devoted Health Medicare |
$21.88
|
| Rate for Payer: Devoted Health Medicare |
$29.82
|
| Rate for Payer: Devoted Health Medicare |
$23.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.51
|
| Rate for Payer: Health Management Network Commercial |
$46.09
|
| Rate for Payer: Health Management Network Commercial |
$33.82
|
| Rate for Payer: Health Management Network Commercial |
$35.79
|
| Rate for Payer: Humana Medicare |
$19.89
|
| Rate for Payer: Humana Medicare |
$21.05
|
| Rate for Payer: Humana Medicare |
$27.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.11
|
| Rate for Payer: MDX Hawaii PPO |
$52.59
|
| Rate for Payer: MDX Hawaii PPO |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$38.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.11
|
| Rate for Payer: University Health Alliance Commercial |
$29.00
|
| Rate for Payer: University Health Alliance Commercial |
$30.69
|
| Rate for Payer: University Health Alliance Commercial |
$39.52
|
|
|
DOBUTamine 250 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$54.22
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
2500266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.09 |
| Max. Negotiated Rate |
$52.59 |
| Rate for Payer: Cash Price |
$35.24
|
| Rate for Payer: Cash Price |
$27.37
|
| Rate for Payer: Cash Price |
$25.86
|
| Rate for Payer: Health Management Network Commercial |
$33.82
|
| Rate for Payer: Health Management Network Commercial |
$46.09
|
| Rate for Payer: Health Management Network Commercial |
$35.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.81
|
| Rate for Payer: MDX Hawaii PPO |
$40.85
|
| Rate for Payer: MDX Hawaii PPO |
$38.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.59
|
|
|
docusate sodium 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
| Hospital Charge Code |
2500267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
docusate sodium 100 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904718361
|
| Hospital Charge Code |
2500267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.31 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$89.50
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Devoted Health Medicare |
$98.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$51.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$51.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.31
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$89.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.50
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.50
|
| Rate for Payer: University Health Alliance Commercial |
$94.96
|
|
|
DOH - SARS CoV-2 (COVID-19) by RT-PCR FSI
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
8862906
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
DOH Testing FSI
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
8117902
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
DOH Testing FSI
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
8117902
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$45.00
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Devoted Health Medicare |
$49.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.63
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$45.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.00
|
| Rate for Payer: University Health Alliance Commercial |
$17.13
|
|
|
donepezil 5 mg tablet [HHSC]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
2500271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: AlohaCare Medicaid |
$2.16
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.10
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: University Health Alliance Commercial |
$3.15
|
|
|
donepezil 5 mg tablet [HHSC]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
2500271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
|
|
DOPamine-D5W 400 mg/250 ml premix [HHSC]
|
Facility
|
OP
|
$79.24
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$76.86 |
| Rate for Payer: AlohaCare Medicaid |
$39.62
|
| Rate for Payer: AlohaCare Medicaid |
$48.30
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: AlohaCare Medicare |
$39.62
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Devoted Health Medicare |
$43.58
|
| Rate for Payer: Devoted Health Medicare |
$53.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.77
|
| Rate for Payer: Health Management Network Commercial |
$82.11
|
| Rate for Payer: Health Management Network Commercial |
$67.35
|
| Rate for Payer: Humana Medicare |
$39.62
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$76.86
|
| Rate for Payer: MDX Hawaii PPO |
$93.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$57.76
|
| Rate for Payer: University Health Alliance Commercial |
$70.41
|
|
|
DOPamine-D5W 400 mg/250 ml premix [HHSC]
|
Facility
|
IP
|
$79.24
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$76.86 |
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Health Management Network Commercial |
$67.35
|
| Rate for Payer: Health Management Network Commercial |
$82.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.94
|
| Rate for Payer: MDX Hawaii PPO |
$93.70
|
| Rate for Payer: MDX Hawaii PPO |
$76.86
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, NARROW, LEFT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, NARROW, LEFT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, LEFT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, LEFT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, RIGHT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, RIGHT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
doxepin 50 mg capsule [HHSC]
|
Facility
|
IP
|
$6.55
|
|
|
Service Code
|
NDC 49884021901
|
| Hospital Charge Code |
2500275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Cash Price |
$4.26
|
| Rate for Payer: Health Management Network Commercial |
$5.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$6.35
|
|
|
doxepin 50 mg capsule [HHSC]
|
Facility
|
OP
|
$6.55
|
|
|
Service Code
|
NDC 27241016901
|
| Hospital Charge Code |
2500275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: AlohaCare Medicaid |
$3.27
|
| Rate for Payer: AlohaCare Medicare |
$3.27
|
| Rate for Payer: Cash Price |
$4.26
|
| Rate for Payer: Devoted Health Medicare |
$3.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.22
|
| Rate for Payer: Health Management Network Commercial |
$5.57
|
| Rate for Payer: Humana Medicare |
$3.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.27
|
| Rate for Payer: MDX Hawaii PPO |
$6.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.27
|
| Rate for Payer: University Health Alliance Commercial |
$4.77
|
|
|
doxepin 50 mg capsule [HHSC]
|
Facility
|
OP
|
$6.55
|
|
|
Service Code
|
NDC 00378425001
|
| Hospital Charge Code |
2500275
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: AlohaCare Medicaid |
$3.27
|
| Rate for Payer: AlohaCare Medicare |
$3.27
|
| Rate for Payer: Cash Price |
$4.26
|
| Rate for Payer: Devoted Health Medicare |
$3.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.22
|
| Rate for Payer: Health Management Network Commercial |
$5.57
|
| Rate for Payer: Humana Medicare |
$3.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.27
|
| Rate for Payer: MDX Hawaii PPO |
$6.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.27
|
| Rate for Payer: University Health Alliance Commercial |
$4.77
|
|
