|
PERCUTANEOUS LIVER BIOPSY† - 00702
|
Professional
|
Both
|
$191.00
|
|
| Hospital Charge Code |
8970940
|
|
Hospital Revenue Code
|
963
|
| Min. Negotiated Rate |
$162.35 |
| Max. Negotiated Rate |
$162.35 |
| Rate for Payer: Cash Price |
$124.15
|
| Rate for Payer: Health Management Network Commercial |
$162.35
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR
|
Facility
|
IP
|
$58,093.60
|
|
|
Service Code
|
MSDRG 041
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$58,093.60 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$58,093.60
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC
|
Facility
|
IP
|
$66,057.47
|
|
|
Service Code
|
MSDRG 040
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$66,057.47 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$66,057.47
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$50,106.03
|
|
|
Service Code
|
MSDRG 042
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$50,106.03 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,106.03
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
Peripherally Inserted Central Catheter Insertion
|
Facility
|
IP
|
$3,286.00
|
|
|
Service Code
|
HCPCS 36569
|
| Hospital Charge Code |
607646
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,793.10 |
| Max. Negotiated Rate |
$3,187.42 |
| Rate for Payer: Cash Price |
$2,135.90
|
| Rate for Payer: Health Management Network Commercial |
$2,793.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,957.40
|
| Rate for Payer: MDX Hawaii PPO |
$3,187.42
|
|
|
Peripherally Inserted Central Catheter Insertion
|
Facility
|
OP
|
$3,286.00
|
|
|
Service Code
|
HCPCS 36569
|
| Hospital Charge Code |
607646
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$3,187.42 |
| Rate for Payer: AlohaCare Medicaid |
$1,643.00
|
| Rate for Payer: AlohaCare Medicare |
$1,643.00
|
| Rate for Payer: Cash Price |
$2,135.90
|
| Rate for Payer: Cash Price |
$2,135.90
|
| Rate for Payer: Devoted Health Medicare |
$1,807.30
|
| 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 |
$1,643.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,121.70
|
| Rate for Payer: Health Management Network Commercial |
$2,793.10
|
| Rate for Payer: Humana Medicare |
$1,643.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,957.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,643.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,187.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,643.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,643.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,643.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,395.17
|
|
|
PERIPHERAL VASCULAR DISORDERS WITH CC
|
Facility
|
IP
|
$24,531.57
|
|
|
Service Code
|
MSDRG 300
|
| Min. Negotiated Rate |
$24,531.57 |
| Max. Negotiated Rate |
$24,531.57 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,531.57
|
|
|
PERIPHERAL VASCULAR DISORDERS WITH MCC
|
Facility
|
IP
|
$26,024.80
|
|
|
Service Code
|
MSDRG 299
|
| Min. Negotiated Rate |
$26,024.80 |
| Max. Negotiated Rate |
$26,024.80 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,024.80
|
|
|
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$18,060.92
|
|
|
Service Code
|
MSDRG 301
|
| Min. Negotiated Rate |
$18,060.92 |
| Max. Negotiated Rate |
$18,060.92 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18,060.92
|
|
|
PERITONEAL ADHESIOLYSIS WITH CC
|
Facility
|
IP
|
$53,400.61
|
|
|
Service Code
|
MSDRG 336
|
| Min. Negotiated Rate |
$53,400.61 |
| Max. Negotiated Rate |
$53,400.61 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$53,400.61
|
|
|
PERITONEAL ADHESIOLYSIS WITH MCC
|
Facility
|
IP
|
$60,416.40
|
|
|
Service Code
|
MSDRG 335
|
| Min. Negotiated Rate |
$60,416.40 |
| Max. Negotiated Rate |
$60,416.40 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60,416.40
|
|
|
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$32,779.87
|
|
|
Service Code
|
MSDRG 337
|
| Min. Negotiated Rate |
$32,779.87 |
| Max. Negotiated Rate |
$32,779.87 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,779.87
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC
|
Facility
|
IP
|
$53,519.12
|
|
|
Service Code
|
MSDRG 243
|
| Min. Negotiated Rate |
$53,519.12 |
| Max. Negotiated Rate |
$53,519.12 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$53,519.12
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC
|
Facility
|
IP
|
$71,580.04
|
|
|
Service Code
|
MSDRG 242
|
| Min. Negotiated Rate |
$71,580.04 |
| Max. Negotiated Rate |
$71,580.04 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$71,580.04
|
|
|
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$43,967.21
|
|
|
Service Code
|
MSDRG 244
|
| Min. Negotiated Rate |
$43,967.21 |
| Max. Negotiated Rate |
$43,967.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43,967.21
|
|
|
permethrin 1% 60 ml lotion [HHSC]
|
Facility
|
OP
|
$61.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.62 |
| Max. Negotiated Rate |
$59.41 |
| Rate for Payer: AlohaCare Medicaid |
$30.62
|
| Rate for Payer: AlohaCare Medicaid |
$29.39
|
| Rate for Payer: AlohaCare Medicare |
$29.39
|
| Rate for Payer: AlohaCare Medicare |
$30.62
|
| Rate for Payer: Cash Price |
$38.20
|
| Rate for Payer: Cash Price |
$39.81
|
| Rate for Payer: Devoted Health Medicare |
$32.32
|
| Rate for Payer: Devoted Health Medicare |
$33.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.83
|
| Rate for Payer: Health Management Network Commercial |
$49.95
|
| Rate for Payer: Health Management Network Commercial |
$52.06
|
| Rate for Payer: Humana Medicare |
$29.39
|
| Rate for Payer: Humana Medicare |
$30.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.39
|
| Rate for Payer: MDX Hawaii PPO |
$59.41
|
| Rate for Payer: MDX Hawaii PPO |
$57.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.62
|
| Rate for Payer: University Health Alliance Commercial |
$32.91
|
| Rate for Payer: University Health Alliance Commercial |
$34.30
|
|
|
permethrin 1% 60 ml lotion [HHSC]
|
Facility
|
IP
|
$61.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.06 |
| Max. Negotiated Rate |
$59.41 |
| Rate for Payer: Cash Price |
$39.81
|
| Rate for Payer: Cash Price |
$38.20
|
| Rate for Payer: Health Management Network Commercial |
$49.95
|
| Rate for Payer: Health Management Network Commercial |
$52.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.12
|
| Rate for Payer: MDX Hawaii PPO |
$59.41
|
| Rate for Payer: MDX Hawaii PPO |
$57.01
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
OP
|
$500.64
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$250.32 |
| Max. Negotiated Rate |
$485.62 |
| Rate for Payer: AlohaCare Medicaid |
$250.32
|
| Rate for Payer: AlohaCare Medicare |
$250.32
|
| Rate for Payer: Cash Price |
$325.42
|
| Rate for Payer: Devoted Health Medicare |
$275.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$250.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$475.61
|
| Rate for Payer: Health Management Network Commercial |
$425.54
|
| Rate for Payer: Humana Medicare |
$250.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$255.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$250.32
|
| Rate for Payer: MDX Hawaii PPO |
$485.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$250.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$250.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$300.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$250.32
|
| Rate for Payer: University Health Alliance Commercial |
$364.92
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
IP
|
$488.62
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$415.33 |
| Max. Negotiated Rate |
$473.96 |
| Rate for Payer: Cash Price |
$317.60
|
| Rate for Payer: Health Management Network Commercial |
$415.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.76
|
| Rate for Payer: MDX Hawaii PPO |
$473.96
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
IP
|
$490.29
|
|
|
Service Code
|
NDC 45802026937
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$416.75 |
| Max. Negotiated Rate |
$475.58 |
| Rate for Payer: Cash Price |
$318.69
|
| Rate for Payer: Health Management Network Commercial |
$416.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.26
|
| Rate for Payer: MDX Hawaii PPO |
$475.58
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
OP
|
$488.62
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.31 |
| Max. Negotiated Rate |
$473.96 |
| Rate for Payer: AlohaCare Medicaid |
$244.31
|
| Rate for Payer: AlohaCare Medicare |
$244.31
|
| Rate for Payer: Cash Price |
$317.60
|
| Rate for Payer: Devoted Health Medicare |
$268.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$244.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.19
|
| Rate for Payer: Health Management Network Commercial |
$415.33
|
| Rate for Payer: Humana Medicare |
$244.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$249.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$244.31
|
| Rate for Payer: MDX Hawaii PPO |
$473.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$244.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$244.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$293.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$244.31
|
| Rate for Payer: University Health Alliance Commercial |
$356.16
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
IP
|
$500.64
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$425.54 |
| Max. Negotiated Rate |
$485.62 |
| Rate for Payer: Cash Price |
$325.42
|
| Rate for Payer: Health Management Network Commercial |
$425.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$450.58
|
| Rate for Payer: MDX Hawaii PPO |
$485.62
|
|
|
permethrin 5% cream topical [HHSC]
|
Facility
|
OP
|
$490.29
|
|
|
Service Code
|
NDC 45802026937
|
| Hospital Charge Code |
2500643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$245.15 |
| Max. Negotiated Rate |
$475.58 |
| Rate for Payer: AlohaCare Medicaid |
$245.15
|
| Rate for Payer: AlohaCare Medicare |
$245.15
|
| Rate for Payer: Cash Price |
$318.69
|
| Rate for Payer: Devoted Health Medicare |
$269.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$465.78
|
| Rate for Payer: Health Management Network Commercial |
$416.75
|
| Rate for Payer: Humana Medicare |
$245.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$250.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.15
|
| Rate for Payer: MDX Hawaii PPO |
$475.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$294.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.15
|
| Rate for Payer: University Health Alliance Commercial |
$357.37
|
|
|
Pfizer vaccine 2nd dose: 0002A - 30mcg - Pfizer Vaccine Admin Charge
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS 0002A
|
| Hospital Charge Code |
9250669
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$71.00 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$71.00
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Devoted Health Medicare |
$78.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$71.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.00
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.00
|
| Rate for Payer: University Health Alliance Commercial |
$79.52
|
|
|
Pfizer vaccine 2nd dose: 0002A - 30mcg - Pfizer Vaccine Admin Charge
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS 0002A
|
| Hospital Charge Code |
9250669
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
