|
nitroprusside 50 mg/2 ml vial [HHSC]
|
Facility
|
IP
|
$118.47
|
|
|
Service Code
|
NDC 43598058723
|
| Hospital Charge Code |
2500592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.70 |
| Max. Negotiated Rate |
$114.92 |
| Rate for Payer: Cash Price |
$77.01
|
| Rate for Payer: Health Management Network Commercial |
$100.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.62
|
| Rate for Payer: MDX Hawaii PPO |
$114.92
|
|
|
Nitrous Oxide Gas Charge Per Hour
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
9864762
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$12.50
|
| Rate for Payer: Cash Price |
$16.25
|
| Rate for Payer: Devoted Health Medicare |
$13.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$12.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.50
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
Nitrous Oxide Gas Charge Per Hour
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
9864762
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$16.25
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
Nitrous Oxide-OB
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
9752159
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
Nitrous Oxide-OB
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
9752159
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$10.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Devoted Health Medicare |
$11.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$10.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.00
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
NMDA IgG Receptor Ab Rfx Titer, CSF FSI
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS 86255
|
| Hospital Charge Code |
8228902
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: AlohaCare Medicaid |
$69.50
|
| Rate for Payer: AlohaCare Medicare |
$69.50
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Devoted Health Medicare |
$76.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.05
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Humana Medicare |
$69.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.50
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.15
|
|
|
NMDA IgG Receptor Ab Rfx Titer, CSF FSI
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS 86255
|
| Hospital Charge Code |
8228902
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$118.15 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC
|
Facility
|
IP
|
$37,543.97
|
|
|
Service Code
|
MSDRG 098
|
| Min. Negotiated Rate |
$37,543.97 |
| Max. Negotiated Rate |
$37,543.97 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,543.97
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC
|
Facility
|
IP
|
$37,543.97
|
|
|
Service Code
|
MSDRG 097
|
| Min. Negotiated Rate |
$37,543.97 |
| Max. Negotiated Rate |
$37,543.97 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,543.97
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$37,543.97
|
|
|
Service Code
|
MSDRG 099
|
| Min. Negotiated Rate |
$37,543.97 |
| Max. Negotiated Rate |
$37,543.97 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,543.97
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$38,018.01
|
|
|
Service Code
|
MSDRG 988
|
| Min. Negotiated Rate |
$38,018.01 |
| Max. Negotiated Rate |
$38,018.01 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$38,018.01
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$38,018.01
|
|
|
Service Code
|
MSDRG 987
|
| Min. Negotiated Rate |
$38,018.01 |
| Max. Negotiated Rate |
$38,018.01 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$38,018.01
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$38,018.01
|
|
|
Service Code
|
MSDRG 989
|
| Min. Negotiated Rate |
$38,018.01 |
| Max. Negotiated Rate |
$38,018.01 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$38,018.01
|
|
|
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$15,998.85
|
|
|
Service Code
|
MSDRG 600
|
| Min. Negotiated Rate |
$15,998.85 |
| Max. Negotiated Rate |
$15,998.85 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,998.85
|
|
|
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$15,998.85
|
|
|
Service Code
|
MSDRG 601
|
| Min. Negotiated Rate |
$15,998.85 |
| Max. Negotiated Rate |
$15,998.85 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,998.85
|
|
|
Non-Selective Debridement Charge
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
HCPCS 97602 GP,CQ
|
| Hospital Charge Code |
8111712
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$414.80 |
| Max. Negotiated Rate |
$473.36 |
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.20
|
| Rate for Payer: MDX Hawaii PPO |
$473.36
|
|
|
Non-Selective Debridement Charge
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
HCPCS 97602 GP,CQ
|
| Hospital Charge Code |
8111712
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$473.36 |
| Rate for Payer: AlohaCare Medicaid |
$244.00
|
| Rate for Payer: AlohaCare Medicare |
$244.00
|
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Cash Price |
$317.20
|
| Rate for Payer: Devoted Health Medicare |
$268.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$244.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$463.60
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Humana Medicare |
$244.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$248.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$244.00
|
| Rate for Payer: MDX Hawaii PPO |
$473.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$244.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$244.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$244.00
|
| Rate for Payer: University Health Alliance Commercial |
$273.28
|
|
|
NONTRAUMATIC STUPOR AND COMA WITH MCC
|
Facility
|
IP
|
$32,566.55
|
|
|
Service Code
|
MSDRG 080
|
| Min. Negotiated Rate |
$32,566.55 |
| Max. Negotiated Rate |
$32,566.55 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,566.55
|
|
|
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC
|
Facility
|
IP
|
$32,566.55
|
|
|
Service Code
|
MSDRG 081
|
| Min. Negotiated Rate |
$32,566.55 |
| Max. Negotiated Rate |
$32,566.55 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,566.55
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
IP
|
$115.34
|
|
|
Service Code
|
NDC 00409337504
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.04 |
| Max. Negotiated Rate |
$111.88 |
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: Health Management Network Commercial |
$98.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.81
|
| Rate for Payer: MDX Hawaii PPO |
$111.88
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
IP
|
$115.39
|
|
|
Service Code
|
NDC 00409337525
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.08 |
| Max. Negotiated Rate |
$111.93 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Health Management Network Commercial |
$98.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.85
|
| Rate for Payer: MDX Hawaii PPO |
$111.93
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
IP
|
$108.54
|
|
|
Service Code
|
NDC 00703115303
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.26 |
| Max. Negotiated Rate |
$105.28 |
| Rate for Payer: Cash Price |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$92.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.69
|
| Rate for Payer: MDX Hawaii PPO |
$105.28
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
OP
|
$115.34
|
|
|
Service Code
|
NDC 00409337504
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.67 |
| Max. Negotiated Rate |
$111.88 |
| Rate for Payer: AlohaCare Medicaid |
$57.67
|
| Rate for Payer: AlohaCare Medicare |
$57.67
|
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: Devoted Health Medicare |
$63.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.57
|
| Rate for Payer: Health Management Network Commercial |
$98.04
|
| Rate for Payer: Humana Medicare |
$57.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.67
|
| Rate for Payer: MDX Hawaii PPO |
$111.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.67
|
| Rate for Payer: University Health Alliance Commercial |
$84.07
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
OP
|
$108.54
|
|
|
Service Code
|
NDC 00703115303
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.27 |
| Max. Negotiated Rate |
$105.28 |
| Rate for Payer: AlohaCare Medicaid |
$54.27
|
| Rate for Payer: AlohaCare Medicare |
$54.27
|
| Rate for Payer: Cash Price |
$70.55
|
| Rate for Payer: Devoted Health Medicare |
$59.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.11
|
| Rate for Payer: Health Management Network Commercial |
$92.26
|
| Rate for Payer: Humana Medicare |
$54.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.27
|
| Rate for Payer: MDX Hawaii PPO |
$105.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.27
|
| Rate for Payer: University Health Alliance Commercial |
$79.11
|
|
|
norEPINEPHrine 4 mg/4 ml vial [HHSC]
|
Facility
|
OP
|
$115.39
|
|
|
Service Code
|
NDC 00409337525
|
| Hospital Charge Code |
2500593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.70 |
| Max. Negotiated Rate |
$111.93 |
| Rate for Payer: AlohaCare Medicaid |
$57.70
|
| Rate for Payer: AlohaCare Medicare |
$57.70
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Devoted Health Medicare |
$63.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.62
|
| Rate for Payer: Health Management Network Commercial |
$98.08
|
| Rate for Payer: Humana Medicare |
$57.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.70
|
| Rate for Payer: MDX Hawaii PPO |
$111.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.70
|
| Rate for Payer: University Health Alliance Commercial |
$84.11
|
|
