|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$10,499.99
|
|
|
Service Code
|
MSDRG 555
|
| Min. Negotiated Rate |
$10,499.99 |
| Max. Negotiated Rate |
$10,499.99 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,499.99
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
|
IP
|
$10,499.99
|
|
|
Service Code
|
MSDRG 556
|
| Min. Negotiated Rate |
$10,499.99 |
| Max. Negotiated Rate |
$10,499.99 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,499.99
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$14,387.11
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$14,387.11 |
| Max. Negotiated Rate |
$14,387.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,387.11
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$13,676.05
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$13,676.05 |
| Max. Negotiated Rate |
$13,676.05 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,676.05
|
|
|
silver nitrate stick, topical [HHSC]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 12870000101
|
| Hospital Charge Code |
2500741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$3.85
|
|
|
silver nitrate stick, topical [HHSC]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 12870000101
|
| Hospital Charge Code |
2500741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: AlohaCare Medicaid |
$1.99
|
| Rate for Payer: AlohaCare Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Devoted Health Medicare |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.77
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Humana Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.99
|
| Rate for Payer: MDX Hawaii PPO |
$3.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.99
|
| Rate for Payer: University Health Alliance Commercial |
$2.89
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
OP
|
$53.85
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.93 |
| Max. Negotiated Rate |
$52.23 |
| Rate for Payer: AlohaCare Medicaid |
$26.93
|
| Rate for Payer: AlohaCare Medicare |
$26.93
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Devoted Health Medicare |
$29.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.16
|
| Rate for Payer: Health Management Network Commercial |
$45.77
|
| Rate for Payer: Humana Medicare |
$26.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.93
|
| Rate for Payer: MDX Hawaii PPO |
$52.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.93
|
| Rate for Payer: University Health Alliance Commercial |
$39.25
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
IP
|
$53.46
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$51.86 |
| Rate for Payer: Cash Price |
$34.75
|
| Rate for Payer: Health Management Network Commercial |
$45.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.11
|
| Rate for Payer: MDX Hawaii PPO |
$51.86
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
OP
|
$53.46
|
|
|
Service Code
|
NDC 61570013125
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.73 |
| Max. Negotiated Rate |
$51.86 |
| Rate for Payer: AlohaCare Medicaid |
$26.73
|
| Rate for Payer: AlohaCare Medicare |
$26.73
|
| Rate for Payer: Cash Price |
$34.75
|
| Rate for Payer: Devoted Health Medicare |
$29.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.79
|
| Rate for Payer: Health Management Network Commercial |
$45.44
|
| Rate for Payer: Humana Medicare |
$26.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.73
|
| Rate for Payer: MDX Hawaii PPO |
$51.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.73
|
| Rate for Payer: University Health Alliance Commercial |
$38.97
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
OP
|
$53.46
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.73 |
| Max. Negotiated Rate |
$51.86 |
| Rate for Payer: AlohaCare Medicaid |
$26.73
|
| Rate for Payer: AlohaCare Medicare |
$26.73
|
| Rate for Payer: Cash Price |
$34.75
|
| Rate for Payer: Devoted Health Medicare |
$29.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.79
|
| Rate for Payer: Health Management Network Commercial |
$45.44
|
| Rate for Payer: Humana Medicare |
$26.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.73
|
| Rate for Payer: MDX Hawaii PPO |
$51.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.73
|
| Rate for Payer: University Health Alliance Commercial |
$38.97
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
IP
|
$53.46
|
|
|
Service Code
|
NDC 61570013125
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$51.86 |
| Rate for Payer: Cash Price |
$34.75
|
| Rate for Payer: Health Management Network Commercial |
$45.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.11
|
| Rate for Payer: MDX Hawaii PPO |
$51.86
|
|
|
silver sulfADIAZINE 1% 25gm cream [HHSC]
|
Facility
|
IP
|
$53.85
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
2500744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.77 |
| Max. Negotiated Rate |
$52.23 |
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Health Management Network Commercial |
$45.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.47
|
| Rate for Payer: MDX Hawaii PPO |
$52.23
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
OP
|
$137.71
|
|
|
Service Code
|
NDC 61570013185
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.86 |
| Max. Negotiated Rate |
$133.58 |
| Rate for Payer: AlohaCare Medicaid |
$68.86
|
| Rate for Payer: AlohaCare Medicare |
$68.86
|
| Rate for Payer: Cash Price |
$89.51
|
| Rate for Payer: Devoted Health Medicare |
$75.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$130.82
|
| Rate for Payer: Health Management Network Commercial |
$117.05
|
| Rate for Payer: Humana Medicare |
$68.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.86
|
| Rate for Payer: MDX Hawaii PPO |
$133.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.86
|
| Rate for Payer: University Health Alliance Commercial |
$100.38
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
IP
|
$132.06
|
|
|
Service Code
|
NDC 67877012485
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.25 |
| Max. Negotiated Rate |
$128.10 |
| Rate for Payer: Cash Price |
$85.84
|
| Rate for Payer: Health Management Network Commercial |
$112.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.85
|
| Rate for Payer: MDX Hawaii PPO |
$128.10
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
OP
|
$132.06
|
|
|
Service Code
|
NDC 67877012485
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.03 |
| Max. Negotiated Rate |
$128.10 |
| Rate for Payer: AlohaCare Medicaid |
$66.03
|
| Rate for Payer: AlohaCare Medicare |
$66.03
|
| Rate for Payer: Cash Price |
$85.84
|
| Rate for Payer: Devoted Health Medicare |
$72.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.46
|
| Rate for Payer: Health Management Network Commercial |
$112.25
|
| Rate for Payer: Humana Medicare |
$66.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.03
|
| Rate for Payer: MDX Hawaii PPO |
$128.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$79.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.03
|
| Rate for Payer: University Health Alliance Commercial |
$96.26
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
IP
|
$137.71
|
|
|
Service Code
|
NDC 61570013185
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.05 |
| Max. Negotiated Rate |
$133.58 |
| Rate for Payer: Cash Price |
$89.51
|
| Rate for Payer: Health Management Network Commercial |
$117.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.94
|
| Rate for Payer: MDX Hawaii PPO |
$133.58
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
IP
|
$128.79
|
|
|
Service Code
|
NDC 43598021085
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.47 |
| Max. Negotiated Rate |
$124.93 |
| Rate for Payer: Cash Price |
$83.71
|
| Rate for Payer: Health Management Network Commercial |
$109.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.91
|
| Rate for Payer: MDX Hawaii PPO |
$124.93
|
|
|
silver sulfADIAZINE 1% 85gm cream [HHSC]
|
Facility
|
OP
|
$128.79
|
|
|
Service Code
|
NDC 43598021085
|
| Hospital Charge Code |
2500743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.39 |
| Max. Negotiated Rate |
$124.93 |
| Rate for Payer: AlohaCare Medicaid |
$64.39
|
| Rate for Payer: AlohaCare Medicare |
$64.39
|
| Rate for Payer: Cash Price |
$83.71
|
| Rate for Payer: Devoted Health Medicare |
$70.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.35
|
| Rate for Payer: Health Management Network Commercial |
$109.47
|
| Rate for Payer: Humana Medicare |
$64.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.39
|
| Rate for Payer: MDX Hawaii PPO |
$124.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.39
|
| Rate for Payer: University Health Alliance Commercial |
$93.88
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
IP
|
$326.46
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$277.49 |
| Max. Negotiated Rate |
$316.67 |
| Rate for Payer: Cash Price |
$212.20
|
| Rate for Payer: Health Management Network Commercial |
$277.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$293.81
|
| Rate for Payer: MDX Hawaii PPO |
$316.67
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
IP
|
$346.31
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$294.36 |
| Max. Negotiated Rate |
$335.92 |
| Rate for Payer: Cash Price |
$225.10
|
| Rate for Payer: Health Management Network Commercial |
$294.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.68
|
| Rate for Payer: MDX Hawaii PPO |
$335.92
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
OP
|
$321.72
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.86 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: AlohaCare Medicaid |
$160.86
|
| Rate for Payer: AlohaCare Medicare |
$160.86
|
| Rate for Payer: Cash Price |
$209.12
|
| Rate for Payer: Devoted Health Medicare |
$176.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$305.63
|
| Rate for Payer: Health Management Network Commercial |
$273.46
|
| Rate for Payer: Humana Medicare |
$160.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$289.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$164.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.86
|
| Rate for Payer: MDX Hawaii PPO |
$312.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$193.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.86
|
| Rate for Payer: University Health Alliance Commercial |
$234.50
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
IP
|
$321.72
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.46 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: Cash Price |
$209.12
|
| Rate for Payer: Health Management Network Commercial |
$273.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$289.55
|
| Rate for Payer: MDX Hawaii PPO |
$312.07
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
OP
|
$326.46
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.23 |
| Max. Negotiated Rate |
$316.67 |
| Rate for Payer: AlohaCare Medicaid |
$163.23
|
| Rate for Payer: AlohaCare Medicare |
$163.23
|
| Rate for Payer: Cash Price |
$212.20
|
| Rate for Payer: Devoted Health Medicare |
$179.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$163.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$310.14
|
| Rate for Payer: Health Management Network Commercial |
$277.49
|
| Rate for Payer: Humana Medicare |
$163.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$293.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$166.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$163.23
|
| Rate for Payer: MDX Hawaii PPO |
$316.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$163.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$163.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$195.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$163.23
|
| Rate for Payer: University Health Alliance Commercial |
$237.96
|
|
|
silver sulfADIAZINE Top 1% Crm 400g [HHSC]
|
Facility
|
OP
|
$346.31
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
2500742
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$173.16 |
| Max. Negotiated Rate |
$335.92 |
| Rate for Payer: AlohaCare Medicaid |
$173.16
|
| Rate for Payer: AlohaCare Medicare |
$173.16
|
| Rate for Payer: Cash Price |
$225.10
|
| Rate for Payer: Devoted Health Medicare |
$190.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$173.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$328.99
|
| Rate for Payer: Health Management Network Commercial |
$294.36
|
| Rate for Payer: Humana Medicare |
$173.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$176.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$173.16
|
| Rate for Payer: MDX Hawaii PPO |
$335.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$173.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$173.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$173.16
|
| Rate for Payer: University Health Alliance Commercial |
$252.43
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$23,796.81
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$23,796.81 |
| Max. Negotiated Rate |
$23,796.81 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,796.81
|
|
