|
GENERAL:PLUS PUMP
|
Facility
|
OP
|
$2,739.00
|
|
| Hospital Charge Code |
12818168
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,369.50 |
| Max. Negotiated Rate |
$2,656.83 |
| Rate for Payer: AlohaCare Medicaid |
$1,369.50
|
| Rate for Payer: AlohaCare Medicare |
$1,369.50
|
| Rate for Payer: Cash Price |
$1,780.35
|
| Rate for Payer: Devoted Health Medicare |
$1,506.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,369.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,602.05
|
| Rate for Payer: Health Management Network Commercial |
$2,328.15
|
| Rate for Payer: Humana Medicare |
$1,369.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,465.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,396.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,369.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,656.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,369.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,369.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,369.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,996.46
|
|
|
GENERAL:PLUS PUMP
|
Facility
|
IP
|
$2,739.00
|
|
| Hospital Charge Code |
12818168
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,328.15 |
| Max. Negotiated Rate |
$2,656.83 |
| Rate for Payer: Cash Price |
$1,780.35
|
| Rate for Payer: Health Management Network Commercial |
$2,328.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,465.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,656.83
|
|
|
GENERAL:PREV CUSTOMIZABLE DRESSING
|
Facility
|
OP
|
$2,571.00
|
|
| Hospital Charge Code |
12818175
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,285.50 |
| Max. Negotiated Rate |
$2,493.87 |
| Rate for Payer: AlohaCare Medicaid |
$1,285.50
|
| Rate for Payer: AlohaCare Medicare |
$1,285.50
|
| Rate for Payer: Cash Price |
$1,671.15
|
| Rate for Payer: Devoted Health Medicare |
$1,414.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,285.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,442.45
|
| Rate for Payer: Health Management Network Commercial |
$2,185.35
|
| Rate for Payer: Humana Medicare |
$1,285.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,313.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,311.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,285.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,493.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,285.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,285.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,285.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,874.00
|
|
|
GENERAL:PREV CUSTOMIZABLE DRESSING
|
Facility
|
IP
|
$2,571.00
|
|
| Hospital Charge Code |
12818175
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,185.35 |
| Max. Negotiated Rate |
$2,493.87 |
| Rate for Payer: Cash Price |
$1,671.15
|
| Rate for Payer: Health Management Network Commercial |
$2,185.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,313.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,493.87
|
|
|
GENERAL:RESTRATA MINI MATRIX 250MG
|
Facility
|
OP
|
$2,980.00
|
|
|
Service Code
|
HCPCS A2026
|
| Hospital Charge Code |
12815065
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,490.00 |
| Max. Negotiated Rate |
$2,890.60 |
| Rate for Payer: AlohaCare Medicaid |
$1,490.00
|
| Rate for Payer: AlohaCare Medicare |
$1,490.00
|
| Rate for Payer: Cash Price |
$1,937.00
|
| Rate for Payer: Devoted Health Medicare |
$1,639.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,490.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,831.00
|
| Rate for Payer: Health Management Network Commercial |
$2,533.00
|
| Rate for Payer: Humana Medicare |
$1,490.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,682.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,519.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,490.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,890.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,490.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,490.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,490.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,172.12
|
|
|
GENERAL:RESTRATA MINI MATRIX 250MG
|
Facility
|
IP
|
$2,980.00
|
|
|
Service Code
|
HCPCS A2026
|
| Hospital Charge Code |
12815065
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,533.00 |
| Max. Negotiated Rate |
$2,890.60 |
| Rate for Payer: Cash Price |
$1,937.00
|
| Rate for Payer: Health Management Network Commercial |
$2,533.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,682.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,890.60
|
|
|
GENERAL:SONICICION
|
Facility
|
IP
|
$1,400.00
|
|
| Hospital Charge Code |
12818169
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,190.00 |
| Max. Negotiated Rate |
$1,358.00 |
| Rate for Payer: Cash Price |
$910.00
|
| Rate for Payer: Health Management Network Commercial |
$1,190.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,260.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,358.00
|
|
|
GENERAL:SONICICION
|
Facility
|
OP
|
$1,400.00
|
|
| Hospital Charge Code |
12818169
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$1,358.00 |
| Rate for Payer: AlohaCare Medicaid |
$700.00
|
| Rate for Payer: AlohaCare Medicare |
$700.00
|
| Rate for Payer: Cash Price |
$910.00
|
| Rate for Payer: Devoted Health Medicare |
$770.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$700.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,330.00
|
| Rate for Payer: Health Management Network Commercial |
$1,190.00
|
| Rate for Payer: Humana Medicare |
$700.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,260.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$714.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$700.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,358.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$700.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$700.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$700.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,020.46
|
|
|
Genital Culture, Aerobic Anaerobic FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117920
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
Genital Culture, Aerobic Anaerobic FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117920
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Genital Culture w/ Gram Stain, Aerobic Anaerobic FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117919
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
Genital Culture w/ Gram Stain, Aerobic Anaerobic FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117919
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$98.32
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.16 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: AlohaCare Medicaid |
$49.16
|
| Rate for Payer: AlohaCare Medicare |
$49.16
|
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Devoted Health Medicare |
$54.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.40
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Humana Medicare |
$49.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.16
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.16
|
| Rate for Payer: University Health Alliance Commercial |
$71.67
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$98.32
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$197.26
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.67 |
| Max. Negotiated Rate |
$191.34 |
| Rate for Payer: Cash Price |
$128.22
|
| Rate for Payer: Health Management Network Commercial |
$167.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.53
|
| Rate for Payer: MDX Hawaii PPO |
$191.34
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
IP
|
$108.86
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$105.59 |
| Rate for Payer: Cash Price |
$70.76
|
| Rate for Payer: Health Management Network Commercial |
$92.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.97
|
| Rate for Payer: MDX Hawaii PPO |
$105.59
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$108.86
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.43 |
| Max. Negotiated Rate |
$105.59 |
| Rate for Payer: AlohaCare Medicaid |
$54.43
|
| Rate for Payer: AlohaCare Medicare |
$54.43
|
| Rate for Payer: Cash Price |
$70.76
|
| Rate for Payer: Devoted Health Medicare |
$59.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.42
|
| Rate for Payer: Health Management Network Commercial |
$92.53
|
| Rate for Payer: Humana Medicare |
$54.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.43
|
| Rate for Payer: MDX Hawaii PPO |
$105.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.43
|
| Rate for Payer: University Health Alliance Commercial |
$79.35
|
|
|
gentamicin 0.3% ophth drops [HHSC]
|
Facility
|
OP
|
$197.26
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
2500355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.63 |
| Max. Negotiated Rate |
$191.34 |
| Rate for Payer: AlohaCare Medicaid |
$98.63
|
| Rate for Payer: AlohaCare Medicare |
$98.63
|
| Rate for Payer: Cash Price |
$128.22
|
| Rate for Payer: Devoted Health Medicare |
$108.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$187.40
|
| Rate for Payer: Health Management Network Commercial |
$167.67
|
| Rate for Payer: Humana Medicare |
$98.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.63
|
| Rate for Payer: MDX Hawaii PPO |
$191.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$118.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.63
|
| Rate for Payer: University Health Alliance Commercial |
$143.78
|
|
|
gentamicin 80 mg/2ml vial [HHSC]
|
Facility
|
OP
|
$21.55
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: AlohaCare Medicaid |
$10.78
|
| Rate for Payer: AlohaCare Medicaid |
$4.22
|
| Rate for Payer: AlohaCare Medicare |
$4.22
|
| Rate for Payer: AlohaCare Medicare |
$10.78
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Devoted Health Medicare |
$11.85
|
| Rate for Payer: Devoted Health Medicare |
$4.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.02
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Health Management Network Commercial |
$18.32
|
| Rate for Payer: Humana Medicare |
$10.78
|
| Rate for Payer: Humana Medicare |
$4.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.22
|
| Rate for Payer: MDX Hawaii PPO |
$20.90
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.22
|
| Rate for Payer: University Health Alliance Commercial |
$15.71
|
| Rate for Payer: University Health Alliance Commercial |
$6.15
|
|
|
gentamicin 80 mg/2ml vial [HHSC]
|
Facility
|
IP
|
$21.55
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2500353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Cash Price |
$14.01
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Health Management Network Commercial |
$18.32
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
| Rate for Payer: MDX Hawaii PPO |
$20.90
|
|
|
Gentamicin Peak FSI
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.20 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
|
|
Gentamicin Peak FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451516
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
|
Gentamicin Random FSI
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.20 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
|
|
Gentamicin Random FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
|
Gentamicin Trough FSI
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 80170
|
| Hospital Charge Code |
8451089
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: AlohaCare Medicaid |
$86.00
|
| Rate for Payer: AlohaCare Medicare |
$86.00
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Cash Price |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$94.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.38
|
| Rate for Payer: Health Management Network Commercial |
$146.20
|
| Rate for Payer: Humana Medicare |
$86.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.00
|
| Rate for Payer: MDX Hawaii PPO |
$166.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.00
|
| Rate for Payer: University Health Alliance Commercial |
$42.37
|
|
