|
Immunoglobulin IgM SO
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 82784
|
| Hospital Charge Code |
9699803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$61.11 |
| Rate for Payer: Cash Price |
$40.95
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.70
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
|
|
Immunoglobulin Panel (IgG, IgA, IgM) FSI
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 82784
|
| Hospital Charge Code |
9699800
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: AlohaCare Medicaid |
$39.00
|
| Rate for Payer: AlohaCare Medicare |
$39.00
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Devoted Health Medicare |
$42.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10.55
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.30
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Humana Medicare |
$39.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.00
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.00
|
| Rate for Payer: University Health Alliance Commercial |
$19.74
|
|
|
Immunoglobulin Panel (IgG, IgA, IgM) FSI
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 82784
|
| Hospital Charge Code |
9699800
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
|
|
INBORN AND OTHER DISORDERS OF METABOLISM
|
Facility
|
IP
|
$85,327.20
|
|
|
Service Code
|
MSDRG 642
|
| Min. Negotiated Rate |
$85,327.20 |
| Max. Negotiated Rate |
$85,327.20 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$85,327.20
|
|
|
Incision and drainage of submucosal abscess, rectum
|
Facility
|
OP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 45005
|
| Hospital Charge Code |
8848346
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$775.50
|
| Rate for Payer: AlohaCare Medicare |
$775.50
|
| Rate for Payer: Cash Price |
$1,008.15
|
| Rate for Payer: Cash Price |
$1,008.15
|
| Rate for Payer: Devoted Health Medicare |
$853.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$775.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,473.45
|
| Rate for Payer: Health Management Network Commercial |
$1,318.35
|
| Rate for Payer: Humana Medicare |
$775.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,395.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$775.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,504.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$775.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$775.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$775.50
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
Incision and drainage of submucosal abscess, rectum
|
Facility
|
IP
|
$1,551.00
|
|
|
Service Code
|
HCPCS 45005
|
| Hospital Charge Code |
8848346
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,318.35 |
| Max. Negotiated Rate |
$1,504.47 |
| Rate for Payer: Cash Price |
$1,008.15
|
| Rate for Payer: Health Management Network Commercial |
$1,318.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,395.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,504.47
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68462040601
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079019020
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68462040601
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
indomethacin 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079019020
|
| Hospital Charge Code |
2500413
|
|
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
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 854
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 853
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 855
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
Infectious Mono Test FSI
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
8117971
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$78.20 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
|
|
Infectious Mono Test FSI
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 86308
|
| Hospital Charge Code |
8117971
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: AlohaCare Medicaid |
$46.00
|
| Rate for Payer: AlohaCare Medicare |
$46.00
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Cash Price |
$59.80
|
| Rate for Payer: Devoted Health Medicare |
$50.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.18
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Humana Medicare |
$46.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.00
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.00
|
| Rate for Payer: University Health Alliance Commercial |
$13.38
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$13,178.31
|
|
|
Service Code
|
MSDRG 727
|
| Min. Negotiated Rate |
$13,178.31 |
| Max. Negotiated Rate |
$13,178.31 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,178.31
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC
|
Facility
|
IP
|
$13,178.31
|
|
|
Service Code
|
MSDRG 728
|
| Min. Negotiated Rate |
$13,178.31 |
| Max. Negotiated Rate |
$13,178.31 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,178.31
|
|
|
INFLAMMATORY BOWEL DISEASE WITH CC
|
Facility
|
IP
|
$19,435.64
|
|
|
Service Code
|
MSDRG 386
|
| Min. Negotiated Rate |
$19,435.64 |
| Max. Negotiated Rate |
$19,435.64 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,435.64
|
|
|
INFLAMMATORY BOWEL DISEASE WITH MCC
|
Facility
|
IP
|
$19,435.64
|
|
|
Service Code
|
MSDRG 385
|
| Min. Negotiated Rate |
$19,435.64 |
| Max. Negotiated Rate |
$19,435.64 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,435.64
|
|
|
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$19,435.64
|
|
|
Service Code
|
MSDRG 387
|
| Min. Negotiated Rate |
$19,435.64 |
| Max. Negotiated Rate |
$19,435.64 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,435.64
|
|
