|
OLANZapine 5 mg ODT [HHSC]
|
Facility
|
OP
|
$11.54
|
|
|
Service Code
|
NDC 55111026281
|
| Hospital Charge Code |
2500609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$11.19 |
| Rate for Payer: AlohaCare Medicaid |
$5.77
|
| Rate for Payer: AlohaCare Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Devoted Health Medicare |
$6.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.96
|
| Rate for Payer: Health Management Network Commercial |
$9.81
|
| Rate for Payer: Humana Medicare |
$5.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.77
|
| Rate for Payer: MDX Hawaii PPO |
$11.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.77
|
| Rate for Payer: University Health Alliance Commercial |
$8.41
|
|
|
OLANZapine 5 mg ODT [HHSC]
|
Facility
|
IP
|
$77.82
|
|
|
Service Code
|
NDC 59746030632
|
| Hospital Charge Code |
2500609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$75.49 |
| Rate for Payer: Cash Price |
$50.58
|
| Rate for Payer: Health Management Network Commercial |
$66.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.04
|
| Rate for Payer: MDX Hawaii PPO |
$75.49
|
|
|
OLANZapine 5 mg ODT [HHSC]
|
Facility
|
IP
|
$77.81
|
|
|
Service Code
|
NDC 64380017202
|
| Hospital Charge Code |
2500609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.14 |
| Max. Negotiated Rate |
$75.48 |
| Rate for Payer: Cash Price |
$50.58
|
| Rate for Payer: Health Management Network Commercial |
$66.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.03
|
| Rate for Payer: MDX Hawaii PPO |
$75.48
|
|
|
OLANZapine 5 mg ODT [HHSC]
|
Facility
|
OP
|
$77.81
|
|
|
Service Code
|
NDC 64380017202
|
| Hospital Charge Code |
2500609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.91 |
| Max. Negotiated Rate |
$75.48 |
| Rate for Payer: AlohaCare Medicaid |
$38.91
|
| Rate for Payer: AlohaCare Medicare |
$38.91
|
| Rate for Payer: Cash Price |
$50.58
|
| Rate for Payer: Devoted Health Medicare |
$42.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.92
|
| Rate for Payer: Health Management Network Commercial |
$66.14
|
| Rate for Payer: Humana Medicare |
$38.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.91
|
| Rate for Payer: MDX Hawaii PPO |
$75.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.91
|
| Rate for Payer: University Health Alliance Commercial |
$56.72
|
|
|
OLANZapine 5 mg ODT [HHSC]
|
Facility
|
IP
|
$77.81
|
|
|
Service Code
|
NDC 49884032055
|
| Hospital Charge Code |
2500609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.14 |
| Max. Negotiated Rate |
$75.48 |
| Rate for Payer: Cash Price |
$50.58
|
| Rate for Payer: Health Management Network Commercial |
$66.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.03
|
| Rate for Payer: MDX Hawaii PPO |
$75.48
|
|
|
Olanzapine and Metabolite
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12516678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: AlohaCare Medicaid |
$175.00
|
| Rate for Payer: AlohaCare Medicare |
$175.00
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Devoted Health Medicare |
$192.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$297.50
|
| Rate for Payer: Humana Medicare |
$175.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$178.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.00
|
| Rate for Payer: MDX Hawaii PPO |
$339.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.00
|
| Rate for Payer: University Health Alliance Commercial |
$35.39
|
|
|
Olanzapine and Metabolite
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12516678
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$297.50 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Health Management Network Commercial |
$297.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.00
|
| Rate for Payer: MDX Hawaii PPO |
$339.50
|
|
|
Olanzapine Level FSI
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12220757
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: AlohaCare Medicaid |
$184.00
|
| Rate for Payer: AlohaCare Medicare |
$184.00
|
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Devoted Health Medicare |
$202.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$184.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Humana Medicare |
$184.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$187.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$184.00
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$184.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$184.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$184.00
|
| Rate for Payer: University Health Alliance Commercial |
$35.39
|
|
|
Olanzapine Level FSI
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
12220757
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$312.80 |
| Max. Negotiated Rate |
$356.96 |
| Rate for Payer: Cash Price |
$239.20
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
|
|
ondansetron 4 mg/2 ml vial [HHSC]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
2500611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$4.99
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$5.39
|
| Rate for Payer: Health Management Network Commercial |
$6.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
| Rate for Payer: MDX Hawaii PPO |
$6.15
|
| Rate for Payer: MDX Hawaii PPO |
$7.44
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
ondansetron 4 mg/2 ml vial [HHSC]
|
Facility
|
OP
|
$6.34
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
2500611
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: AlohaCare Medicaid |
$3.17
|
| Rate for Payer: AlohaCare Medicaid |
$3.83
|
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicaid |
$1.54
|
| Rate for Payer: AlohaCare Medicare |
$1.54
|
| Rate for Payer: AlohaCare Medicare |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.17
|
| Rate for Payer: AlohaCare Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Cash Price |
$4.99
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$4.99
|
| Rate for Payer: Devoted Health Medicare |
$2.20
|
| Rate for Payer: Devoted Health Medicare |
$3.49
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Devoted Health Medicare |
$4.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.29
|
| Rate for Payer: Health Management Network Commercial |
$6.52
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Health Management Network Commercial |
$5.39
|
| Rate for Payer: Humana Medicare |
$2.00
|
| Rate for Payer: Humana Medicare |
$1.54
|
| Rate for Payer: Humana Medicare |
$3.17
|
| Rate for Payer: Humana Medicare |
$3.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.54
|
| Rate for Payer: MDX Hawaii PPO |
$7.44
|
| Rate for Payer: MDX Hawaii PPO |
$6.15
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.54
|
| Rate for Payer: University Health Alliance Commercial |
$5.59
|
| Rate for Payer: University Health Alliance Commercial |
$4.62
|
| Rate for Payer: University Health Alliance Commercial |
$2.25
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
ondansetron 4 mg ODT [HHSC]
|
Facility
|
IP
|
$114.76
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
2500612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.55 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Cash Price |
$74.59
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Cash Price |
$72.34
|
| Rate for Payer: Health Management Network Commercial |
$94.60
|
| Rate for Payer: Health Management Network Commercial |
$97.55
|
| Rate for Payer: Health Management Network Commercial |
$94.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.16
|
| Rate for Payer: MDX Hawaii PPO |
$107.99
|
| Rate for Payer: MDX Hawaii PPO |
$107.95
|
| Rate for Payer: MDX Hawaii PPO |
$111.32
|
|
|
ondansetron 4 mg ODT [HHSC]
|
Facility
|
OP
|
$111.29
|
|
|
Service Code
|
HCPCS Q0162
|
| Hospital Charge Code |
2500612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$107.95 |
| Rate for Payer: AlohaCare Medicaid |
$55.65
|
| Rate for Payer: AlohaCare Medicaid |
$57.38
|
| Rate for Payer: AlohaCare Medicaid |
$55.66
|
| Rate for Payer: AlohaCare Medicare |
$55.66
|
| Rate for Payer: AlohaCare Medicare |
$55.65
|
| Rate for Payer: AlohaCare Medicare |
$57.38
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Cash Price |
$74.59
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Cash Price |
$72.34
|
| Rate for Payer: Cash Price |
$72.34
|
| Rate for Payer: Cash Price |
$74.59
|
| Rate for Payer: Devoted Health Medicare |
$61.21
|
| Rate for Payer: Devoted Health Medicare |
$63.12
|
| Rate for Payer: Devoted Health Medicare |
$61.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.02
|
| Rate for Payer: Health Management Network Commercial |
$97.55
|
| Rate for Payer: Health Management Network Commercial |
$94.60
|
| Rate for Payer: Health Management Network Commercial |
$94.63
|
| Rate for Payer: Humana Medicare |
$55.65
|
| Rate for Payer: Humana Medicare |
$55.66
|
| Rate for Payer: Humana Medicare |
$57.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.38
|
| Rate for Payer: MDX Hawaii PPO |
$111.32
|
| Rate for Payer: MDX Hawaii PPO |
$107.99
|
| Rate for Payer: MDX Hawaii PPO |
$107.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.38
|
| Rate for Payer: University Health Alliance Commercial |
$62.32
|
| Rate for Payer: University Health Alliance Commercial |
$62.34
|
| Rate for Payer: University Health Alliance Commercial |
$64.27
|
|
|
Ondansetron, oral, 4 mg
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
HCPCS S0119
|
| Hospital Charge Code |
12959033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$21.59 |
| Rate for Payer: Cash Price |
$14.95
|
| Rate for Payer: Cash Price |
$14.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.59
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
|
|
.Opiates, Ur Confirm FSI
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8118005
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$422.92 |
| Rate for Payer: AlohaCare Medicaid |
$218.00
|
| Rate for Payer: AlohaCare Medicare |
$218.00
|
| Rate for Payer: Cash Price |
$283.40
|
| Rate for Payer: Cash Price |
$283.40
|
| Rate for Payer: Devoted Health Medicare |
$239.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$143.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$218.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$414.20
|
| Rate for Payer: Health Management Network Commercial |
$370.60
|
| Rate for Payer: Humana Medicare |
$218.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$392.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$222.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$218.00
|
| Rate for Payer: MDX Hawaii PPO |
$422.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$218.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$218.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$218.00
|
| Rate for Payer: University Health Alliance Commercial |
$244.16
|
|
|
.Opiates, Ur Confirm FSI
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
8118005
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$370.60 |
| Max. Negotiated Rate |
$422.92 |
| Rate for Payer: Cash Price |
$283.40
|
| Rate for Payer: Health Management Network Commercial |
$370.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$392.40
|
| Rate for Payer: MDX Hawaii PPO |
$422.92
|
|
|
Opiates, Urine Screen FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1,176.40 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
|
|
Opiates, Urine Screen FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: AlohaCare Medicaid |
$692.00
|
| Rate for Payer: AlohaCare Medicare |
$692.00
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Devoted Health Medicare |
$761.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$77.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.14
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Humana Medicare |
$692.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$705.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$692.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$692.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$692.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$692.00
|
| Rate for Payer: University Health Alliance Commercial |
$147.65
|
|
|
OPTH AHMED GLAUCOMA STENT
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
8348088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,037.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,050.00
|
| Rate for Payer: AlohaCare Medicare |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,365.00
|
| Rate for Payer: Devoted Health Medicare |
$1,155.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,050.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,470.00
|
| Rate for Payer: Health Management Network Commercial |
$1,785.00
|
| Rate for Payer: Humana Medicare |
$1,050.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,890.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,071.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,050.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,037.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,050.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,050.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,050.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,176.00
|
|
|
OPTH AHMED GLAUCOMA STENT
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
8348088
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,176.00 |
| Max. Negotiated Rate |
$2,037.00 |
| Rate for Payer: Cash Price |
$1,365.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,470.00
|
| Rate for Payer: Health Management Network Commercial |
$1,785.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,037.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,176.00
|
|
|
OPTH:AMBIO 5 DEHYDRATED HUMAN AMNIOTIC MEMBRANE ALLOGRAFT 1.5 X 2CM
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
8833859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.72 |
| Max. Negotiated Rate |
$1,757.64 |
| Rate for Payer: Cash Price |
$1,177.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,268.40
|
| Rate for Payer: Health Management Network Commercial |
$1,540.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,630.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,757.64
|
| Rate for Payer: University Health Alliance Commercial |
$1,014.72
|
|
|
OPTH:AMBIO 5 DEHYDRATED HUMAN AMNIOTIC MEMBRANE ALLOGRAFT 1.5 X 2CM
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
8833859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$906.00 |
| Max. Negotiated Rate |
$1,757.64 |
| Rate for Payer: AlohaCare Medicaid |
$906.00
|
| Rate for Payer: AlohaCare Medicare |
$906.00
|
| Rate for Payer: Cash Price |
$1,177.80
|
| Rate for Payer: Devoted Health Medicare |
$996.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$906.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,268.40
|
| Rate for Payer: Health Management Network Commercial |
$1,540.20
|
| Rate for Payer: Humana Medicare |
$906.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,630.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$924.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$906.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,757.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$906.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$906.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$906.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,014.72
|
|
|
OPTH:AMNIOGRAFT, CRYOPRESERVED 2.5x2.0
|
Facility
|
OP
|
$2,700.00
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
12191636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,350.00
|
| Rate for Payer: AlohaCare Medicare |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Devoted Health Medicare |
$1,485.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,350.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Humana Medicare |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,377.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,350.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,350.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,350.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
OPTH:AMNIOGRAFT, CRYOPRESERVED 2.5x2.0
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
12191636
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
OPTH ANGLED MICRO-NEEDLE ELECTRODE E1653
|
Facility
|
OP
|
$130.00
|
|
| Hospital Charge Code |
9024307
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: AlohaCare Medicaid |
$65.00
|
| Rate for Payer: AlohaCare Medicare |
$65.00
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Devoted Health Medicare |
$71.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Humana Medicare |
$65.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.00
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.00
|
| Rate for Payer: University Health Alliance Commercial |
$94.76
|
|
