|
midazolam 2 mg/2 ml vial [HHSC]
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
2500549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: AlohaCare Medicaid |
$2.17
|
| Rate for Payer: AlohaCare Medicaid |
$2.93
|
| Rate for Payer: AlohaCare Medicaid |
$2.13
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.13
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: AlohaCare Medicare |
$2.93
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$3.81
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$3.81
|
| Rate for Payer: Devoted Health Medicare |
$2.35
|
| Rate for Payer: Devoted Health Medicare |
$2.39
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Devoted Health Medicare |
$3.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.57
|
| Rate for Payer: Health Management Network Commercial |
$4.98
|
| Rate for Payer: Health Management Network Commercial |
$3.63
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$3.69
|
| Rate for Payer: Humana Medicare |
$2.13
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Humana Medicare |
$2.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$5.68
|
| Rate for Payer: MDX Hawaii PPO |
$4.21
|
| Rate for Payer: MDX Hawaii PPO |
$4.14
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$4.27
|
| Rate for Payer: University Health Alliance Commercial |
$3.16
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$3.11
|
|
|
midazolam 50 mg/10 ml vial [HHSC]
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
2500550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: AlohaCare Medicaid |
$25.00
|
| Rate for Payer: AlohaCare Medicare |
$25.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Devoted Health Medicare |
$27.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.50
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Humana Medicare |
$25.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.00
|
| Rate for Payer: University Health Alliance Commercial |
$36.45
|
|
|
midazolam 50 mg/10 ml vial [HHSC]
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
2500550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
|
|
Midline Catheter Insertion
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS 36410
|
| Hospital Charge Code |
1766318
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$296.65 |
| Max. Negotiated Rate |
$338.53 |
| Rate for Payer: Cash Price |
$226.85
|
| Rate for Payer: Health Management Network Commercial |
$296.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$314.10
|
| Rate for Payer: MDX Hawaii PPO |
$338.53
|
|
|
Midline Catheter Insertion
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
HCPCS 36410
|
| Hospital Charge Code |
1766318
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$174.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$174.50
|
| Rate for Payer: AlohaCare Medicare |
$174.50
|
| Rate for Payer: Cash Price |
$226.85
|
| Rate for Payer: Cash Price |
$226.85
|
| Rate for Payer: Devoted Health Medicare |
$191.95
|
| 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 |
$174.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$331.55
|
| Rate for Payer: Health Management Network Commercial |
$296.65
|
| Rate for Payer: Humana Medicare |
$174.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$314.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.50
|
| Rate for Payer: MDX Hawaii PPO |
$338.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.50
|
| Rate for Payer: University Health Alliance Commercial |
$254.39
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 50268056115
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: AlohaCare Medicaid |
$2.86
|
| Rate for Payer: AlohaCare Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Devoted Health Medicare |
$3.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.43
|
| Rate for Payer: Health Management Network Commercial |
$4.86
|
| Rate for Payer: Humana Medicare |
$2.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.86
|
| Rate for Payer: University Health Alliance Commercial |
$4.17
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$6.72
|
|
|
Service Code
|
NDC 60505132001
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Health Management Network Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.05
|
| Rate for Payer: MDX Hawaii PPO |
$6.52
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
NDC 00245021111
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: AlohaCare Medicaid |
$4.70
|
| Rate for Payer: AlohaCare Medicare |
$4.70
|
| Rate for Payer: Cash Price |
$6.11
|
| Rate for Payer: Devoted Health Medicare |
$5.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.93
|
| Rate for Payer: Health Management Network Commercial |
$7.99
|
| Rate for Payer: Humana Medicare |
$4.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.70
|
| Rate for Payer: MDX Hawaii PPO |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.70
|
| Rate for Payer: University Health Alliance Commercial |
$6.85
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$6.72
|
|
|
Service Code
|
NDC 60505132001
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: AlohaCare Medicaid |
$3.36
|
| Rate for Payer: AlohaCare Medicare |
$3.36
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Devoted Health Medicare |
$3.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.38
|
| Rate for Payer: Health Management Network Commercial |
$5.71
|
| Rate for Payer: Humana Medicare |
$3.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.36
|
| Rate for Payer: MDX Hawaii PPO |
$6.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.36
|
| Rate for Payer: University Health Alliance Commercial |
$4.90
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$7.96
|
|
|
Service Code
|
NDC 60687038701
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Health Management Network Commercial |
$6.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.16
|
| Rate for Payer: MDX Hawaii PPO |
$7.72
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$14.76
|
|
|
Service Code
|
NDC 50268056415
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.55 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Cash Price |
$9.59
|
| Rate for Payer: Health Management Network Commercial |
$12.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.28
|
| Rate for Payer: MDX Hawaii PPO |
$14.32
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$14.76
|
|
|
Service Code
|
NDC 50268056415
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: AlohaCare Medicaid |
$7.38
|
| Rate for Payer: AlohaCare Medicare |
$7.38
|
| Rate for Payer: Cash Price |
$9.59
|
| Rate for Payer: Devoted Health Medicare |
$8.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.02
|
| Rate for Payer: Health Management Network Commercial |
$12.55
|
| Rate for Payer: Humana Medicare |
$7.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.38
|
| Rate for Payer: MDX Hawaii PPO |
$14.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.38
|
| Rate for Payer: University Health Alliance Commercial |
$10.76
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
NDC 00245021111
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$9.12 |
| Rate for Payer: Cash Price |
$6.11
|
| Rate for Payer: Health Management Network Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.46
|
| Rate for Payer: MDX Hawaii PPO |
$9.12
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.91
|
|
|
Service Code
|
NDC 00904681706
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$3.79 |
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Health Management Network Commercial |
$3.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.52
|
| Rate for Payer: MDX Hawaii PPO |
$3.79
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.91
|
|
|
Service Code
|
NDC 00904681706
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.79 |
| Rate for Payer: AlohaCare Medicaid |
$1.96
|
| Rate for Payer: AlohaCare Medicare |
$1.96
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Devoted Health Medicare |
$2.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network Commercial |
$3.32
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.96
|
| Rate for Payer: MDX Hawaii PPO |
$3.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.96
|
| Rate for Payer: University Health Alliance Commercial |
$2.85
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 50268056115
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Health Management Network Commercial |
$4.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.15
|
| Rate for Payer: MDX Hawaii PPO |
$5.55
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$7.96
|
|
|
Service Code
|
NDC 60687038701
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: AlohaCare Medicaid |
$3.98
|
| Rate for Payer: AlohaCare Medicare |
$3.98
|
| Rate for Payer: Cash Price |
$5.17
|
| Rate for Payer: Devoted Health Medicare |
$4.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.56
|
| Rate for Payer: Health Management Network Commercial |
$6.77
|
| Rate for Payer: Humana Medicare |
$3.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.98
|
| Rate for Payer: MDX Hawaii PPO |
$7.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.98
|
| Rate for Payer: University Health Alliance Commercial |
$5.80
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$8.45
|
|
|
Service Code
|
NDC 82293000310
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Health Management Network Commercial |
$7.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.61
|
| Rate for Payer: MDX Hawaii PPO |
$8.20
|
|
|
midodrine 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$8.45
|
|
|
Service Code
|
NDC 82293000310
|
| Hospital Charge Code |
2500552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: AlohaCare Medicaid |
$4.22
|
| Rate for Payer: AlohaCare Medicare |
$4.22
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Devoted Health Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.03
|
| Rate for Payer: Health Management Network Commercial |
$7.18
|
| Rate for Payer: Humana Medicare |
$4.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.22
|
| Rate for Payer: MDX Hawaii PPO |
$8.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.22
|
| Rate for Payer: University Health Alliance Commercial |
$6.16
|
|
|
Milk, IgE w/ Reflex Alpha Lactalbumin, Beta Lactalbumin, Casein FSI
|
Facility
|
OP
|
$137.00
|
|
| Hospital Charge Code |
8117995
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$68.50 |
| Max. Negotiated Rate |
$132.89 |
| Rate for Payer: AlohaCare Medicaid |
$68.50
|
| Rate for Payer: AlohaCare Medicare |
$68.50
|
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Devoted Health Medicare |
$75.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$130.15
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Humana Medicare |
$68.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.50
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.50
|
| Rate for Payer: University Health Alliance Commercial |
$76.72
|
|
|
Milk, IgE w/ Reflex Alpha Lactalbumin, Beta Lactalbumin, Casein FSI
|
Facility
|
IP
|
$137.00
|
|
| Hospital Charge Code |
8117995
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$116.45 |
| Max. Negotiated Rate |
$132.89 |
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
|
|
MINOR BLADDER PROCEDURES WITH CC
|
Facility
|
IP
|
$24,365.66
|
|
|
Service Code
|
MSDRG 663
|
| Min. Negotiated Rate |
$24,365.66 |
| Max. Negotiated Rate |
$24,365.66 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,365.66
|
|
|
MINOR BLADDER PROCEDURES WITH MCC
|
Facility
|
IP
|
$32,827.27
|
|
|
Service Code
|
MSDRG 662
|
| Min. Negotiated Rate |
$32,827.27 |
| Max. Negotiated Rate |
$32,827.27 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,827.27
|
|
|
MINOR BLADDER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,151.22
|
|
|
Service Code
|
MSDRG 664
|
| Min. Negotiated Rate |
$19,151.22 |
| Max. Negotiated Rate |
$19,151.22 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,151.22
|
|
|
MINOR SKIN DISORDERS WITH MCC
|
Facility
|
IP
|
$13,913.07
|
|
|
Service Code
|
MSDRG 606
|
| Min. Negotiated Rate |
$13,913.07 |
| Max. Negotiated Rate |
$13,913.07 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,913.07
|
|
