|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$35,363.38
|
|
|
Service Code
|
MSDRG 146
|
| Min. Negotiated Rate |
$35,363.38 |
| Max. Negotiated Rate |
$35,363.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35,363.38
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$35,363.38
|
|
|
Service Code
|
MSDRG 148
|
| Min. Negotiated Rate |
$35,363.38 |
| Max. Negotiated Rate |
$35,363.38 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35,363.38
|
|
|
EBV Epstein Barr Virus Capsid Antigen, IgG, IgM FSI
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS 86665
|
| Hospital Charge Code |
8117903
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
|
|
EBV Epstein Barr Virus Capsid Antigen, IgG, IgM FSI
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS 86665
|
| Hospital Charge Code |
8117903
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: AlohaCare Medicaid |
$50.50
|
| Rate for Payer: AlohaCare Medicare |
$50.50
|
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Devoted Health Medicare |
$55.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$25.07
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.14
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Humana Medicare |
$50.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.50
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.50
|
| Rate for Payer: University Health Alliance Commercial |
$46.90
|
|
|
ECHO DOPPLER COLOR FLOW CHARGE
|
Facility
|
IP
|
$3,040.00
|
|
|
Service Code
|
HCPCS 93306
|
| Hospital Charge Code |
8495487
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$2,584.00 |
| Max. Negotiated Rate |
$2,948.80 |
| Rate for Payer: Cash Price |
$1,976.00
|
| Rate for Payer: Health Management Network Commercial |
$2,584.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,736.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,948.80
|
|
|
ECHO DOPPLER COLOR FLOW CHARGE
|
Facility
|
OP
|
$3,040.00
|
|
|
Service Code
|
HCPCS 93306
|
| Hospital Charge Code |
8495487
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$132.88 |
| Max. Negotiated Rate |
$2,948.80 |
| Rate for Payer: AlohaCare Medicaid |
$1,520.00
|
| Rate for Payer: AlohaCare Medicare |
$1,520.00
|
| Rate for Payer: Cash Price |
$1,976.00
|
| Rate for Payer: Cash Price |
$1,976.00
|
| Rate for Payer: Devoted Health Medicare |
$1,672.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$132.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$697.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,520.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$191.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,888.00
|
| Rate for Payer: Health Management Network Commercial |
$2,584.00
|
| Rate for Payer: Humana Medicare |
$1,520.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,736.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,550.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,520.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,948.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,520.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,520.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$132.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,520.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,702.40
|
|
|
Echovirus Panel, CSF FSI
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS 86658
|
| Hospital Charge Code |
8228865
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: AlohaCare Medicaid |
$50.50
|
| Rate for Payer: AlohaCare Medicare |
$50.50
|
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Devoted Health Medicare |
$55.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.03
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Humana Medicare |
$50.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.50
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.50
|
| Rate for Payer: University Health Alliance Commercial |
$33.67
|
|
|
Echovirus Panel, CSF FSI
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS 86658
|
| Hospital Charge Code |
8228865
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Cash Price |
$65.65
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
|
|
ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$466,787.19
|
|
|
Service Code
|
MSDRG 003
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$466,787.19 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$466,787.19
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
EKG POC
|
Professional
|
Both
|
$92.00
|
|
|
Service Code
|
HCPCS 93000
|
| Hospital Charge Code |
8041485
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$15.21
|
| Rate for Payer: AlohaCare Medicare |
$16.32
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Devoted Health Medicare |
$17.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| 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 Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| 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 Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.55
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.58
|
| 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 |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| 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: Ohana Health Plan Medicaid |
$15.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
EKG POC - Nursing
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
8228954
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$314.50 |
| Max. Negotiated Rate |
$358.90 |
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Health Management Network Commercial |
$314.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.00
|
| Rate for Payer: MDX Hawaii PPO |
$358.90
|
|
|
EKG POC - Nursing
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
8228954
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$358.90 |
| Rate for Payer: AlohaCare Medicaid |
$185.00
|
| Rate for Payer: AlohaCare Medicare |
$185.00
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Devoted Health Medicare |
$203.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$75.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$185.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$351.50
|
| Rate for Payer: Health Management Network Commercial |
$314.50
|
| Rate for Payer: Humana Medicare |
$185.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$185.00
|
| Rate for Payer: MDX Hawaii PPO |
$358.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$185.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$185.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$185.00
|
| Rate for Payer: University Health Alliance Commercial |
$207.20
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (counterforce)
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.70
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
| Rate for Payer: University Health Alliance Commercial |
$80.08
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (counterforce)
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381786
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: AlohaCare Medicaid |
$71.50
|
| Rate for Payer: AlohaCare Medicare |
$71.50
|
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: Cash Price |
$92.95
|
| Rate for Payer: Devoted Health Medicare |
$78.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: Humana Medicare |
$71.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.50
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.50
|
| Rate for Payer: University Health Alliance Commercial |
$80.08
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - long)
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381792
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$206.61 |
| Rate for Payer: AlohaCare Medicaid |
$106.50
|
| Rate for Payer: AlohaCare Medicare |
$106.50
|
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Devoted Health Medicare |
$117.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.10
|
| Rate for Payer: Health Management Network Commercial |
$181.05
|
| Rate for Payer: Humana Medicare |
$106.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.50
|
| Rate for Payer: MDX Hawaii PPO |
$206.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.50
|
| Rate for Payer: University Health Alliance Commercial |
$119.28
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - long)
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381792
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$119.28 |
| Max. Negotiated Rate |
$206.61 |
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.10
|
| Rate for Payer: Health Management Network Commercial |
$181.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.70
|
| Rate for Payer: MDX Hawaii PPO |
$206.61
|
| Rate for Payer: University Health Alliance Commercial |
$119.28
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - short)
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381787
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$119.28 |
| Max. Negotiated Rate |
$206.61 |
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.10
|
| Rate for Payer: Health Management Network Commercial |
$181.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.70
|
| Rate for Payer: MDX Hawaii PPO |
$206.61
|
| Rate for Payer: University Health Alliance Commercial |
$119.28
|
|
|
Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - short)
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
HCPCS L3762
|
| Hospital Charge Code |
13381787
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$206.61 |
| Rate for Payer: AlohaCare Medicaid |
$106.50
|
| Rate for Payer: AlohaCare Medicare |
$106.50
|
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Cash Price |
$138.45
|
| Rate for Payer: Devoted Health Medicare |
$117.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.10
|
| Rate for Payer: Health Management Network Commercial |
$181.05
|
| Rate for Payer: Humana Medicare |
$106.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.50
|
| Rate for Payer: MDX Hawaii PPO |
$206.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.50
|
| Rate for Payer: University Health Alliance Commercial |
$119.28
|
|
|
Electrolytes FSI
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 80051
|
| Hospital Charge Code |
8117904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
Electrolytes FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 80051
|
| Hospital Charge Code |
8117904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.69
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.01
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$18.13
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
IP
|
$113.53
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
IP
|
$117.35
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$113.83 |
| Rate for Payer: Cash Price |
$76.28
|
| Rate for Payer: Health Management Network Commercial |
$99.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.61
|
| Rate for Payer: MDX Hawaii PPO |
$113.83
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
OP
|
$117.35
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.67 |
| Max. Negotiated Rate |
$113.83 |
| Rate for Payer: AlohaCare Medicaid |
$58.67
|
| Rate for Payer: AlohaCare Medicare |
$58.67
|
| Rate for Payer: Cash Price |
$76.28
|
| Rate for Payer: Devoted Health Medicare |
$64.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.48
|
| Rate for Payer: Health Management Network Commercial |
$99.75
|
| Rate for Payer: Humana Medicare |
$58.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.67
|
| Rate for Payer: MDX Hawaii PPO |
$113.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.67
|
| Rate for Payer: University Health Alliance Commercial |
$85.54
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
OP
|
$113.53
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.77 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: AlohaCare Medicaid |
$56.77
|
| Rate for Payer: AlohaCare Medicare |
$56.77
|
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Devoted Health Medicare |
$62.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.85
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Humana Medicare |
$56.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.77
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.77
|
| Rate for Payer: University Health Alliance Commercial |
$82.75
|
|
|
empagliflozin 25 mg tablet [HHSC]
|
Facility
|
IP
|
$113.53
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
2501082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
|