|
FTA-Abs REF
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS 86780
|
| Hospital Charge Code |
8160078
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: AlohaCare Medicaid |
$75.50
|
| Rate for Payer: AlohaCare Medicare |
$75.50
|
| Rate for Payer: Cash Price |
$98.15
|
| Rate for Payer: Cash Price |
$98.15
|
| Rate for Payer: Devoted Health Medicare |
$83.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.97
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.24
|
| Rate for Payer: Health Management Network Commercial |
$128.35
|
| Rate for Payer: Humana Medicare |
$75.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.50
|
| Rate for Payer: MDX Hawaii PPO |
$146.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.09
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$18,985.30
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$18,985.30 |
| Max. Negotiated Rate |
$18,985.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18,985.30
|
|
|
Functional Capacity Eval Charge
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 97750 GP,CQ
|
| Hospital Charge Code |
8111734
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$19.83 |
| Max. Negotiated Rate |
$266.75 |
| Rate for Payer: AlohaCare Medicaid |
$137.50
|
| Rate for Payer: AlohaCare Medicare |
$137.50
|
| Rate for Payer: Cash Price |
$178.75
|
| Rate for Payer: Cash Price |
$178.75
|
| Rate for Payer: Devoted Health Medicare |
$151.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$137.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$261.25
|
| Rate for Payer: Health Management Network Commercial |
$233.75
|
| Rate for Payer: Humana Medicare |
$137.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$247.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$140.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$137.50
|
| Rate for Payer: MDX Hawaii PPO |
$266.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$137.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$137.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$137.50
|
| Rate for Payer: University Health Alliance Commercial |
$154.00
|
|
|
Functional Capacity Eval Charge
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 97750 GP,CQ
|
| Hospital Charge Code |
8111734
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$233.75 |
| Max. Negotiated Rate |
$266.75 |
| Rate for Payer: Cash Price |
$178.75
|
| Rate for Payer: Health Management Network Commercial |
$233.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$247.50
|
| Rate for Payer: MDX Hawaii PPO |
$266.75
|
|
|
FUNCTIONAL RESIDUAL CAPACTITY CHARGE
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
8243390
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$330.65 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: Cash Price |
$252.85
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
|
|
FUNCTIONAL RESIDUAL CAPACTITY CHARGE
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
HCPCS 94727
|
| Hospital Charge Code |
8243390
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$20.65 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: AlohaCare Medicaid |
$194.50
|
| Rate for Payer: AlohaCare Medicare |
$194.50
|
| Rate for Payer: Cash Price |
$252.85
|
| Rate for Payer: Cash Price |
$252.85
|
| Rate for Payer: Devoted Health Medicare |
$213.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$275.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$29.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$369.55
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Humana Medicare |
$194.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.50
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.50
|
| Rate for Payer: University Health Alliance Commercial |
$217.84
|
|
|
Fungitell 1-3BD Glucan FSI
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 84311
|
| Hospital Charge Code |
8228871
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$288.15 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
|
|
Fungitell 1-3BD Glucan FSI
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 84311
|
| Hospital Charge Code |
8228871
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$328.83 |
| Rate for Payer: AlohaCare Medicaid |
$169.50
|
| Rate for Payer: AlohaCare Medicare |
$169.50
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Cash Price |
$220.35
|
| Rate for Payer: Devoted Health Medicare |
$186.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.10
|
| Rate for Payer: Health Management Network Commercial |
$288.15
|
| Rate for Payer: Humana Medicare |
$169.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$305.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.50
|
| Rate for Payer: MDX Hawaii PPO |
$328.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.50
|
| Rate for Payer: University Health Alliance Commercial |
$18.07
|
|
|
Fungus/Yeast Cult, Other FSI
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
8117918
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Devoted Health Medicare |
$55.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.61
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.41
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$50.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.72
|
|
|
Fungus/Yeast Cult, Other FSI
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
8117918
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
furosemide 100mg/10mL vial [HHSC]
|
Facility
|
IP
|
$13.34
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$28.46
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Health Management Network Commercial |
$33.09
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Health Management Network Commercial |
$37.22
|
| Rate for Payer: Health Management Network Commercial |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$22.63
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.41
|
| Rate for Payer: MDX Hawaii PPO |
$25.82
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
| Rate for Payer: MDX Hawaii PPO |
$21.91
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$37.76
|
| Rate for Payer: MDX Hawaii PPO |
$42.48
|
|
|
furosemide 100mg/10mL vial [HHSC]
|
Facility
|
OP
|
$21.35
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: AlohaCare Medicaid |
$10.68
|
| Rate for Payer: AlohaCare Medicaid |
$21.89
|
| Rate for Payer: AlohaCare Medicaid |
$6.67
|
| Rate for Payer: AlohaCare Medicaid |
$13.31
|
| Rate for Payer: AlohaCare Medicaid |
$11.29
|
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicaid |
$19.46
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: AlohaCare Medicare |
$19.46
|
| Rate for Payer: AlohaCare Medicare |
$21.89
|
| Rate for Payer: AlohaCare Medicare |
$10.68
|
| Rate for Payer: AlohaCare Medicare |
$13.31
|
| Rate for Payer: AlohaCare Medicare |
$6.67
|
| Rate for Payer: AlohaCare Medicare |
$11.29
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$28.46
|
| Rate for Payer: Cash Price |
$28.46
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Devoted Health Medicare |
$24.08
|
| Rate for Payer: Devoted Health Medicare |
$21.41
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$14.64
|
| Rate for Payer: Devoted Health Medicare |
$7.34
|
| Rate for Payer: Devoted Health Medicare |
$12.42
|
| Rate for Payer: Devoted Health Medicare |
$11.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.60
|
| Rate for Payer: Health Management Network Commercial |
$33.09
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Health Management Network Commercial |
$37.22
|
| Rate for Payer: Health Management Network Commercial |
$22.63
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$19.20
|
| Rate for Payer: Humana Medicare |
$13.31
|
| Rate for Payer: Humana Medicare |
$21.89
|
| Rate for Payer: Humana Medicare |
$19.46
|
| Rate for Payer: Humana Medicare |
$10.68
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Humana Medicare |
$11.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.67
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: MDX Hawaii PPO |
$42.48
|
| Rate for Payer: MDX Hawaii PPO |
$21.91
|
| Rate for Payer: MDX Hawaii PPO |
$25.82
|
| Rate for Payer: MDX Hawaii PPO |
$37.76
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.68
|
| Rate for Payer: University Health Alliance Commercial |
$19.45
|
| Rate for Payer: University Health Alliance Commercial |
$16.47
|
| Rate for Payer: University Health Alliance Commercial |
$9.72
|
| Rate for Payer: University Health Alliance Commercial |
$28.38
|
| Rate for Payer: University Health Alliance Commercial |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$15.56
|
| Rate for Payer: University Health Alliance Commercial |
$31.92
|
|
|
furosemide 20mg/2mL vial [HHSC]
|
Facility
|
OP
|
$22.82
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500883
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$22.14 |
| Rate for Payer: AlohaCare Medicaid |
$11.41
|
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicaid |
$8.76
|
| Rate for Payer: AlohaCare Medicaid |
$8.09
|
| Rate for Payer: AlohaCare Medicaid |
$9.11
|
| Rate for Payer: AlohaCare Medicaid |
$3.33
|
| Rate for Payer: AlohaCare Medicaid |
$22.90
|
| Rate for Payer: AlohaCare Medicaid |
$13.74
|
| Rate for Payer: AlohaCare Medicare |
$8.09
|
| Rate for Payer: AlohaCare Medicare |
$13.74
|
| Rate for Payer: AlohaCare Medicare |
$11.41
|
| Rate for Payer: AlohaCare Medicare |
$3.33
|
| Rate for Payer: AlohaCare Medicare |
$22.90
|
| Rate for Payer: AlohaCare Medicare |
$8.76
|
| Rate for Payer: AlohaCare Medicare |
$9.11
|
| Rate for Payer: AlohaCare Medicare |
$7.00
|
| Rate for Payer: Cash Price |
$14.83
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cash Price |
$17.87
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cash Price |
$17.87
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$14.83
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Devoted Health Medicare |
$7.71
|
| Rate for Payer: Devoted Health Medicare |
$8.90
|
| Rate for Payer: Devoted Health Medicare |
$10.02
|
| Rate for Payer: Devoted Health Medicare |
$3.67
|
| Rate for Payer: Devoted Health Medicare |
$12.55
|
| Rate for Payer: Devoted Health Medicare |
$25.19
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$9.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.34
|
| Rate for Payer: Health Management Network Commercial |
$38.93
|
| Rate for Payer: Health Management Network Commercial |
$23.37
|
| Rate for Payer: Health Management Network Commercial |
$14.88
|
| Rate for Payer: Health Management Network Commercial |
$13.75
|
| Rate for Payer: Health Management Network Commercial |
$11.91
|
| Rate for Payer: Health Management Network Commercial |
$5.67
|
| Rate for Payer: Health Management Network Commercial |
$19.40
|
| Rate for Payer: Health Management Network Commercial |
$15.48
|
| Rate for Payer: Humana Medicare |
$9.11
|
| Rate for Payer: Humana Medicare |
$11.41
|
| Rate for Payer: Humana Medicare |
$13.74
|
| Rate for Payer: Humana Medicare |
$8.09
|
| Rate for Payer: Humana Medicare |
$8.76
|
| Rate for Payer: Humana Medicare |
$22.90
|
| Rate for Payer: Humana Medicare |
$7.00
|
| Rate for Payer: Humana Medicare |
$3.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.59
|
| Rate for Payer: MDX Hawaii PPO |
$15.69
|
| Rate for Payer: MDX Hawaii PPO |
$26.67
|
| Rate for Payer: MDX Hawaii PPO |
$16.98
|
| Rate for Payer: MDX Hawaii PPO |
$44.43
|
| Rate for Payer: MDX Hawaii PPO |
$22.14
|
| Rate for Payer: MDX Hawaii PPO |
$17.66
|
| Rate for Payer: MDX Hawaii PPO |
$6.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.33
|
| Rate for Payer: University Health Alliance Commercial |
$13.27
|
| Rate for Payer: University Health Alliance Commercial |
$4.86
|
| Rate for Payer: University Health Alliance Commercial |
$33.38
|
| Rate for Payer: University Health Alliance Commercial |
$12.76
|
| Rate for Payer: University Health Alliance Commercial |
$20.04
|
| Rate for Payer: University Health Alliance Commercial |
$10.21
|
| Rate for Payer: University Health Alliance Commercial |
$16.63
|
| Rate for Payer: University Health Alliance Commercial |
$11.79
|
|
|
furosemide 20mg/2mL vial [HHSC]
|
Facility
|
IP
|
$14.01
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500883
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$13.59 |
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cash Price |
$14.83
|
| Rate for Payer: Cash Price |
$17.87
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Health Management Network Commercial |
$23.37
|
| Rate for Payer: Health Management Network Commercial |
$19.40
|
| Rate for Payer: Health Management Network Commercial |
$13.75
|
| Rate for Payer: Health Management Network Commercial |
$5.67
|
| Rate for Payer: Health Management Network Commercial |
$38.93
|
| Rate for Payer: Health Management Network Commercial |
$15.48
|
| Rate for Payer: Health Management Network Commercial |
$14.88
|
| Rate for Payer: Health Management Network Commercial |
$11.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.56
|
| Rate for Payer: MDX Hawaii PPO |
$16.98
|
| Rate for Payer: MDX Hawaii PPO |
$17.66
|
| Rate for Payer: MDX Hawaii PPO |
$15.69
|
| Rate for Payer: MDX Hawaii PPO |
$13.59
|
| Rate for Payer: MDX Hawaii PPO |
$22.14
|
| Rate for Payer: MDX Hawaii PPO |
$6.47
|
| Rate for Payer: MDX Hawaii PPO |
$44.43
|
| Rate for Payer: MDX Hawaii PPO |
$26.67
|
|
|
furosemide 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079007220
|
| Hospital Charge Code |
2500345
|
|
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
|
|
|
furosemide 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079007220
|
| Hospital Charge Code |
2500345
|
|
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
|
|
|
furosemide 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904717761
|
| Hospital Charge Code |
2500345
|
|
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
|
|
|
furosemide 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904717761
|
| Hospital Charge Code |
2500345
|
|
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
|
|
|
furosemide 40 mg/4 mL vial [HHSC]
|
Facility
|
IP
|
$20.15
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500884
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.13 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cash Price |
$11.99
|
| Rate for Payer: Health Management Network Commercial |
$15.67
|
| Rate for Payer: Health Management Network Commercial |
$15.88
|
| Rate for Payer: Health Management Network Commercial |
$15.89
|
| Rate for Payer: Health Management Network Commercial |
$17.13
|
| Rate for Payer: Health Management Network Commercial |
$18.13
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.82
|
| Rate for Payer: MDX Hawaii PPO |
$18.13
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$20.69
|
| Rate for Payer: MDX Hawaii PPO |
$19.55
|
| Rate for Payer: MDX Hawaii PPO |
$17.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.12
|
|
|
furosemide 40 mg/4 mL vial [HHSC]
|
Facility
|
OP
|
$18.44
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
2500884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$17.89 |
| Rate for Payer: AlohaCare Medicaid |
$9.22
|
| Rate for Payer: AlohaCare Medicaid |
$9.34
|
| Rate for Payer: AlohaCare Medicaid |
$9.35
|
| Rate for Payer: AlohaCare Medicaid |
$10.07
|
| Rate for Payer: AlohaCare Medicaid |
$11.68
|
| Rate for Payer: AlohaCare Medicaid |
$10.66
|
| Rate for Payer: AlohaCare Medicare |
$9.35
|
| Rate for Payer: AlohaCare Medicare |
$11.68
|
| Rate for Payer: AlohaCare Medicare |
$9.34
|
| Rate for Payer: AlohaCare Medicare |
$10.66
|
| Rate for Payer: AlohaCare Medicare |
$9.22
|
| Rate for Payer: AlohaCare Medicare |
$10.07
|
| Rate for Payer: Cash Price |
$11.99
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$11.99
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Devoted Health Medicare |
$10.27
|
| Rate for Payer: Devoted Health Medicare |
$12.84
|
| Rate for Payer: Devoted Health Medicare |
$11.08
|
| Rate for Payer: Devoted Health Medicare |
$10.28
|
| Rate for Payer: Devoted Health Medicare |
$10.14
|
| Rate for Payer: Devoted Health Medicare |
$11.73
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.75
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Health Management Network Commercial |
$15.88
|
| Rate for Payer: Health Management Network Commercial |
$18.13
|
| Rate for Payer: Health Management Network Commercial |
$17.13
|
| Rate for Payer: Health Management Network Commercial |
$15.67
|
| Rate for Payer: Health Management Network Commercial |
$15.89
|
| Rate for Payer: Humana Medicare |
$9.34
|
| Rate for Payer: Humana Medicare |
$11.68
|
| Rate for Payer: Humana Medicare |
$9.22
|
| Rate for Payer: Humana Medicare |
$10.07
|
| Rate for Payer: Humana Medicare |
$9.35
|
| Rate for Payer: Humana Medicare |
$10.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.68
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$17.89
|
| Rate for Payer: MDX Hawaii PPO |
$19.55
|
| Rate for Payer: MDX Hawaii PPO |
$20.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.12
|
| Rate for Payer: MDX Hawaii PPO |
$18.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.07
|
| Rate for Payer: University Health Alliance Commercial |
$13.44
|
| Rate for Payer: University Health Alliance Commercial |
$14.69
|
| Rate for Payer: University Health Alliance Commercial |
$15.55
|
| Rate for Payer: University Health Alliance Commercial |
$17.02
|
| Rate for Payer: University Health Alliance Commercial |
$13.62
|
| Rate for Payer: University Health Alliance Commercial |
$13.62
|
|
|
G0008 Administration of influenza virus vaccine
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
8041150
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$63.75 |
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
|
|
G0008 Administration of influenza virus vaccine.
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
9091516
|
|
Hospital Revenue Code
|
771
|
| 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
|
|
|
G0008 Administration of influenza virus vaccine.
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
9091516
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$34.61 |
| 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 Commercial |
$59.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.95
|
| 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 |
$34.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.50
|
| Rate for Payer: University Health Alliance Commercial |
$56.56
|
|
|
G0008 ADMIN OF INFLUENZA VACCINE CHARGE
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
8107366
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: AlohaCare Medicaid |
$56.50
|
| Rate for Payer: AlohaCare Medicare |
$56.50
|
| Rate for Payer: Cash Price |
$73.45
|
| Rate for Payer: Cash Price |
$73.45
|
| Rate for Payer: Devoted Health Medicare |
$62.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$59.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Humana Medicare |
$56.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.50
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.50
|
| Rate for Payer: University Health Alliance Commercial |
$63.28
|
|
|
G0008 ADMIN OF INFLUENZA VACCINE CHARGE
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
8107366
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$73.45
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
