|
fluPHENAZine decanoate 125 mg/5ml vial [HHSC]
|
Facility
|
OP
|
$618.20
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
2500337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$599.65 |
| Rate for Payer: AlohaCare Medicaid |
$309.10
|
| Rate for Payer: AlohaCare Medicaid |
$315.33
|
| Rate for Payer: AlohaCare Medicare |
$315.33
|
| Rate for Payer: AlohaCare Medicare |
$309.10
|
| Rate for Payer: Cash Price |
$409.93
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$409.93
|
| Rate for Payer: Devoted Health Medicare |
$340.01
|
| Rate for Payer: Devoted Health Medicare |
$346.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$315.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$309.10
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$587.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$599.13
|
| Rate for Payer: Health Management Network Commercial |
$536.06
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Humana Medicare |
$309.10
|
| Rate for Payer: Humana Medicare |
$315.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$321.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$309.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$315.33
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
| Rate for Payer: MDX Hawaii PPO |
$611.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$315.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$315.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$378.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$370.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$309.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$315.33
|
| Rate for Payer: University Health Alliance Commercial |
$450.61
|
| Rate for Payer: University Health Alliance Commercial |
$459.69
|
|
|
fluPHENAZine decanoate 125 mg/5ml vial [HHSC]
|
Facility
|
IP
|
$618.20
|
|
|
Service Code
|
HCPCS J2680
|
| Hospital Charge Code |
2500337
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$525.47 |
| Max. Negotiated Rate |
$599.65 |
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$409.93
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Health Management Network Commercial |
$536.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.59
|
| Rate for Payer: MDX Hawaii PPO |
$611.74
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
|
|
FLUTTER VALVE CHARGE
|
Facility
|
OP
|
$173.00
|
|
| Hospital Charge Code |
8243410
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.50 |
| 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: Devoted Health Medicare |
$95.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| 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 Medicare |
$86.50
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
FLUTTER VALVE CHARGE
|
Facility
|
IP
|
$173.00
|
|
| Hospital Charge Code |
8243410
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
flu vaccine triv PF (2025-2026) 0.5 mL PFS [HHSC]
|
Facility
|
IP
|
$122.25
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
2501206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.91 |
| Max. Negotiated Rate |
$118.58 |
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Health Management Network Commercial |
$103.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.03
|
| Rate for Payer: MDX Hawaii PPO |
$118.58
|
|
|
flu vaccine triv PF (2025-2026) 0.5 mL PFS [HHSC]
|
Facility
|
OP
|
$122.25
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
2501206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.35 |
| Max. Negotiated Rate |
$118.58 |
| Rate for Payer: AlohaCare Medicaid |
$61.12
|
| Rate for Payer: AlohaCare Medicare |
$61.12
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Cash Price |
$79.46
|
| Rate for Payer: Devoted Health Medicare |
$67.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.14
|
| Rate for Payer: Health Management Network Commercial |
$103.91
|
| Rate for Payer: Humana Medicare |
$61.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.12
|
| Rate for Payer: MDX Hawaii PPO |
$118.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.12
|
| Rate for Payer: University Health Alliance Commercial |
$68.46
|
|
|
Fngr Open Wrkhard Roylan
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8409629
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: AlohaCare Medicaid |
$51.50
|
| Rate for Payer: AlohaCare Medicare |
$51.50
|
| Rate for Payer: Cash Price |
$66.95
|
| Rate for Payer: Devoted Health Medicare |
$56.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.85
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Humana Medicare |
$51.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.50
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.50
|
| Rate for Payer: University Health Alliance Commercial |
$75.08
|
|
|
Fngr Open Wrkhard Roylan
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8409629
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$87.55 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$66.95
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
|
|
Folate FSI
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 82746
|
| Hospital Charge Code |
8117913
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$141.95 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
Folate FSI
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 82746
|
| Hospital Charge Code |
8117913
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: AlohaCare Medicaid |
$83.50
|
| Rate for Payer: AlohaCare Medicare |
$83.50
|
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Devoted Health Medicare |
$91.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.70
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Humana Medicare |
$83.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.50
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.50
|
| Rate for Payer: University Health Alliance Commercial |
$38.00
|
|
|
Folate, RBC FSI
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS 82747
|
| Hospital Charge Code |
8117914
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$166.60 |
| Max. Negotiated Rate |
$190.12 |
| Rate for Payer: Cash Price |
$127.40
|
| Rate for Payer: Health Management Network Commercial |
$166.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$176.40
|
| Rate for Payer: MDX Hawaii PPO |
$190.12
|
|
|
Folate, RBC FSI
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS 82747
|
| Hospital Charge Code |
8117914
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$190.12 |
| Rate for Payer: AlohaCare Medicaid |
$98.00
|
| Rate for Payer: AlohaCare Medicare |
$98.00
|
| Rate for Payer: Cash Price |
$127.40
|
| Rate for Payer: Cash Price |
$127.40
|
| Rate for Payer: Devoted Health Medicare |
$107.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.93
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$25.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.65
|
| Rate for Payer: Health Management Network Commercial |
$166.60
|
| Rate for Payer: Humana Medicare |
$98.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$176.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.00
|
| Rate for Payer: MDX Hawaii PPO |
$190.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.00
|
| Rate for Payer: University Health Alliance Commercial |
$44.77
|
|
|
folic acid 1 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
2500341
|
|
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
|
|
|
folic acid 1 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
2500341
|
|
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
|
|
|
folic acid 1 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
2500341
|
|
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
|
|
|
folic acid 1 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
2500341
|
|
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
|
|
|
folic acid 50 mg/10ml vial [HHSC]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
2500342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: AlohaCare Medicaid |
$2.43
|
| Rate for Payer: AlohaCare Medicaid |
$3.01
|
| Rate for Payer: AlohaCare Medicare |
$3.01
|
| Rate for Payer: AlohaCare Medicare |
$2.43
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Devoted Health Medicare |
$2.67
|
| Rate for Payer: Devoted Health Medicare |
$3.31
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.72
|
| Rate for Payer: Health Management Network Commercial |
$5.12
|
| Rate for Payer: Health Management Network Commercial |
$4.13
|
| Rate for Payer: Humana Medicare |
$2.43
|
| Rate for Payer: Humana Medicare |
$3.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.01
|
| Rate for Payer: MDX Hawaii PPO |
$4.71
|
| Rate for Payer: MDX Hawaii PPO |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.01
|
| Rate for Payer: University Health Alliance Commercial |
$3.54
|
| Rate for Payer: University Health Alliance Commercial |
$4.39
|
|
|
folic acid 50 mg/10ml vial [HHSC]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
2500342
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: Health Management Network Commercial |
$4.13
|
| Rate for Payer: Health Management Network Commercial |
$5.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.42
|
| Rate for Payer: MDX Hawaii PPO |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$4.71
|
|
|
FOOT PROCEDURES WITH CC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 504
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
FOOT PROCEDURES WITH MCC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 503
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
FOOT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 505
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
fosphenytoin 500 mg (PE)/10 ml vial [HHSC]
|
Facility
|
IP
|
$491.59
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
2500344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$417.85 |
| Max. Negotiated Rate |
$476.84 |
| Rate for Payer: Cash Price |
$319.53
|
| Rate for Payer: Cash Price |
$194.21
|
| Rate for Payer: Health Management Network Commercial |
$253.97
|
| Rate for Payer: Health Management Network Commercial |
$417.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$442.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.91
|
| Rate for Payer: MDX Hawaii PPO |
$289.83
|
| Rate for Payer: MDX Hawaii PPO |
$476.84
|
|
|
fosphenytoin 500 mg (PE)/10 ml vial [HHSC]
|
Facility
|
OP
|
$491.59
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
2500344
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$476.84 |
| Rate for Payer: AlohaCare Medicaid |
$245.79
|
| Rate for Payer: AlohaCare Medicaid |
$149.40
|
| Rate for Payer: AlohaCare Medicare |
$245.79
|
| Rate for Payer: AlohaCare Medicare |
$149.40
|
| Rate for Payer: Cash Price |
$194.21
|
| Rate for Payer: Cash Price |
$194.21
|
| Rate for Payer: Cash Price |
$319.53
|
| Rate for Payer: Cash Price |
$319.53
|
| Rate for Payer: Devoted Health Medicare |
$270.37
|
| Rate for Payer: Devoted Health Medicare |
$164.33
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$149.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$283.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$467.01
|
| Rate for Payer: Health Management Network Commercial |
$417.85
|
| Rate for Payer: Health Management Network Commercial |
$253.97
|
| Rate for Payer: Humana Medicare |
$149.40
|
| Rate for Payer: Humana Medicare |
$245.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$442.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$152.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$250.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.40
|
| Rate for Payer: MDX Hawaii PPO |
$476.84
|
| Rate for Payer: MDX Hawaii PPO |
$289.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$149.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$149.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$294.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$179.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$149.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.79
|
| Rate for Payer: University Health Alliance Commercial |
$167.32
|
| Rate for Payer: University Health Alliance Commercial |
$275.29
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$12,182.83
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$12,182.83 |
| Max. Negotiated Rate |
$12,182.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,182.83
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$12,182.83
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$12,182.83 |
| Max. Negotiated Rate |
$12,182.83 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,182.83
|
|
