|
XR Wrist Complete 3+ Views Left - Report
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 73110 26,LT
|
| Hospital Charge Code |
611597
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: AlohaCare Medicaid |
$27.72
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.77
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.72
|
|
|
XR Wrist Complete 3+ Views Right
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
HCPCS 73110 RT
|
| Hospital Charge Code |
1170614
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: AlohaCare Medicaid |
$262.50
|
| Rate for Payer: AlohaCare Medicare |
$262.50
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Devoted Health Medicare |
$288.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$262.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.75
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Humana Medicare |
$262.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$262.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$262.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$262.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$262.50
|
| Rate for Payer: University Health Alliance Commercial |
$66.60
|
|
|
XR Wrist Complete 3+ Views Right
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
HCPCS 73110 RT
|
| Hospital Charge Code |
1170614
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Cash Price |
$341.25
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
|
|
XR Wrist Complete 3+ Views Right
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
HCPCS 73110 RT
|
| Hospital Charge Code |
1170614
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$27.72
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Cash Price |
$129.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.77
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
XR Wrist Complete 3+ Views Right - Report
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 73110 26,RT
|
| Hospital Charge Code |
611595
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$56.10 |
| Rate for Payer: AlohaCare Medicaid |
$27.72
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.77
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.72
|
|
|
Yes - OT Paraffin Bath Charge
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS 97018 GO
|
| Hospital Charge Code |
8372814
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
Yes - OT Paraffin Bath Charge
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS 97018 GO
|
| Hospital Charge Code |
8372814
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$21.00
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Devoted Health Medicare |
$23.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$21.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.00
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.00
|
| Rate for Payer: University Health Alliance Commercial |
$23.52
|
|
|
Yes - OT Swallow Eval Charge
|
Facility
|
IP
|
$521.00
|
|
|
Service Code
|
HCPCS 92610 GO
|
| Hospital Charge Code |
8450059
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$442.85 |
| Max. Negotiated Rate |
$505.37 |
| Rate for Payer: Cash Price |
$338.65
|
| Rate for Payer: Health Management Network Commercial |
$442.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$468.90
|
| Rate for Payer: MDX Hawaii PPO |
$505.37
|
|
|
Yes - OT Swallow Eval Charge
|
Facility
|
OP
|
$521.00
|
|
|
Service Code
|
HCPCS 92610 GO
|
| Hospital Charge Code |
8450059
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$88.36 |
| Max. Negotiated Rate |
$505.37 |
| Rate for Payer: AlohaCare Medicaid |
$260.50
|
| Rate for Payer: AlohaCare Medicare |
$260.50
|
| Rate for Payer: Cash Price |
$338.65
|
| Rate for Payer: Cash Price |
$338.65
|
| Rate for Payer: Devoted Health Medicare |
$286.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$260.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$494.95
|
| Rate for Payer: Health Management Network Commercial |
$442.85
|
| Rate for Payer: Humana Medicare |
$260.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$468.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$265.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$260.50
|
| Rate for Payer: MDX Hawaii PPO |
$505.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$260.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$260.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$260.50
|
| Rate for Payer: University Health Alliance Commercial |
$291.76
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GP
|
| Hospital Charge Code |
8416253
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GO
|
| Hospital Charge Code |
8246631
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Devoted Health Medicare |
$55.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$50.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.00
|
| Rate for Payer: University Health Alliance Commercial |
$56.00
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GO
|
| Hospital Charge Code |
8246631
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GP
|
| Hospital Charge Code |
8416253
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Devoted Health Medicare |
$55.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$50.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.00
|
| Rate for Payer: University Health Alliance Commercial |
$56.00
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GP,CQ
|
| Hospital Charge Code |
8246629
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Devoted Health Medicare |
$55.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$50.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.00
|
| Rate for Payer: University Health Alliance Commercial |
$56.00
|
|
|
Yes - Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 97014 GP,CQ
|
| Hospital Charge Code |
8246629
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
Y-PLATE, 2.0MM, 6 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.72 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
Y-PLATE, 2.0MM, 6 HOLE
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.00 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: AlohaCare Medicaid |
$731.00
|
| Rate for Payer: AlohaCare Medicare |
$731.00
|
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Devoted Health Medicare |
$804.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$731.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Humana Medicare |
$731.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$745.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$731.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$731.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$731.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$731.00
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
Z0092 School/Sports Physical
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
HCPCS Z0092
|
| Hospital Charge Code |
8197118
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$90.10 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
Zinc, Serum FSI
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 84630
|
| Hospital Charge Code |
8118089
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
|
Zinc, Serum FSI
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 84630
|
| Hospital Charge Code |
8118089
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.39 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$66.00
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Devoted Health Medicare |
$72.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.74
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.39
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.00
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.00
|
| Rate for Payer: University Health Alliance Commercial |
$29.43
|
|
|
ziprasidone 20 mg vial [HHSC]
|
Facility
|
OP
|
$182.62
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
2500868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$177.14 |
| Rate for Payer: AlohaCare Medicaid |
$91.31
|
| Rate for Payer: AlohaCare Medicaid |
$113.08
|
| Rate for Payer: AlohaCare Medicaid |
$59.01
|
| Rate for Payer: AlohaCare Medicare |
$113.08
|
| Rate for Payer: AlohaCare Medicare |
$59.01
|
| Rate for Payer: AlohaCare Medicare |
$91.31
|
| Rate for Payer: Cash Price |
$76.71
|
| Rate for Payer: Cash Price |
$147.01
|
| Rate for Payer: Cash Price |
$76.71
|
| Rate for Payer: Cash Price |
$147.01
|
| Rate for Payer: Cash Price |
$118.70
|
| Rate for Payer: Cash Price |
$118.70
|
| Rate for Payer: Devoted Health Medicare |
$124.39
|
| Rate for Payer: Devoted Health Medicare |
$100.44
|
| Rate for Payer: Devoted Health Medicare |
$64.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$113.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$214.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$173.49
|
| Rate for Payer: Health Management Network Commercial |
$100.32
|
| Rate for Payer: Health Management Network Commercial |
$155.23
|
| Rate for Payer: Health Management Network Commercial |
$192.24
|
| Rate for Payer: Humana Medicare |
$91.31
|
| Rate for Payer: Humana Medicare |
$59.01
|
| Rate for Payer: Humana Medicare |
$113.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.08
|
| Rate for Payer: MDX Hawaii PPO |
$219.38
|
| Rate for Payer: MDX Hawaii PPO |
$114.48
|
| Rate for Payer: MDX Hawaii PPO |
$177.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$113.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$109.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$113.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.31
|
| Rate for Payer: University Health Alliance Commercial |
$164.86
|
| Rate for Payer: University Health Alliance Commercial |
$133.11
|
| Rate for Payer: University Health Alliance Commercial |
$86.02
|
|
|
ziprasidone 20 mg vial [HHSC]
|
Facility
|
IP
|
$182.62
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
2500868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$155.23 |
| Max. Negotiated Rate |
$177.14 |
| Rate for Payer: Cash Price |
$118.70
|
| Rate for Payer: Cash Price |
$76.71
|
| Rate for Payer: Cash Price |
$147.01
|
| Rate for Payer: Health Management Network Commercial |
$192.24
|
| Rate for Payer: Health Management Network Commercial |
$100.32
|
| Rate for Payer: Health Management Network Commercial |
$155.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.36
|
| Rate for Payer: MDX Hawaii PPO |
$177.14
|
| Rate for Payer: MDX Hawaii PPO |
$114.48
|
| Rate for Payer: MDX Hawaii PPO |
$219.38
|
|
|
zolpidem 5 mg tablet [HHSC]
|
Facility
|
OP
|
$25.68
|
|
|
Service Code
|
NDC 51079072420
|
| Hospital Charge Code |
2500871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$24.91 |
| Rate for Payer: AlohaCare Medicaid |
$12.84
|
| Rate for Payer: AlohaCare Medicare |
$12.84
|
| Rate for Payer: Cash Price |
$16.69
|
| Rate for Payer: Devoted Health Medicare |
$14.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.40
|
| Rate for Payer: Health Management Network Commercial |
$21.83
|
| Rate for Payer: Humana Medicare |
$12.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.84
|
| Rate for Payer: MDX Hawaii PPO |
$24.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.84
|
| Rate for Payer: University Health Alliance Commercial |
$18.72
|
|
|
zolpidem 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904608261
|
| Hospital Charge Code |
2500871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
zolpidem 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904608261
|
| Hospital Charge Code |
2500871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
