|
WASHER ASNIS 4.5/6.5/8 619904
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.76 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$172.20
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
| Rate for Payer: University Health Alliance Commercial |
$137.76
|
|
|
WASHER ASNIS 4.5/6.5/8 619904
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.46 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$172.20
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$125.46
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
| Rate for Payer: University Health Alliance Commercial |
$137.76
|
|
|
WASHER FLAT 7.0MM P20-070-WF00
|
Facility
|
IP
|
$633.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$354.48 |
| Max. Negotiated Rate |
$614.01 |
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$443.10
|
| Rate for Payer: Health Management Network Commercial |
$538.05
|
| Rate for Payer: MDX Hawaii PPO |
$614.01
|
| Rate for Payer: University Health Alliance Commercial |
$354.48
|
|
|
WASHER FLAT 7.0MM P20-070-WF00
|
Facility
|
OP
|
$633.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$322.83 |
| Max. Negotiated Rate |
$614.01 |
| Rate for Payer: Cash Price |
$379.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$443.10
|
| Rate for Payer: Health Management Network Commercial |
$538.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$398.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$322.83
|
| Rate for Payer: MDX Hawaii PPO |
$614.01
|
| Rate for Payer: University Health Alliance Commercial |
$354.48
|
|
|
WASHER SLED OLECRANON OSW
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$509.60 |
| Max. Negotiated Rate |
$882.70 |
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$637.00
|
| Rate for Payer: Health Management Network Commercial |
$773.50
|
| Rate for Payer: MDX Hawaii PPO |
$882.70
|
| Rate for Payer: University Health Alliance Commercial |
$509.60
|
|
|
WASHER SLED OLECRANON OSW
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$464.10 |
| Max. Negotiated Rate |
$882.70 |
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$637.00
|
| Rate for Payer: Health Management Network Commercial |
$773.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$573.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$464.10
|
| Rate for Payer: MDX Hawaii PPO |
$882.70
|
| Rate for Payer: University Health Alliance Commercial |
$509.60
|
|
|
WASHER SPIKE 8.0/3.2MM 219.931
|
Facility
|
IP
|
$372.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.32 |
| Max. Negotiated Rate |
$360.84 |
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$260.40
|
| Rate for Payer: Health Management Network Commercial |
$316.20
|
| Rate for Payer: MDX Hawaii PPO |
$360.84
|
| Rate for Payer: University Health Alliance Commercial |
$208.32
|
|
|
WASHER SPIKE 8.0/3.2MM 219.931
|
Facility
|
OP
|
$372.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.72 |
| Max. Negotiated Rate |
$360.84 |
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$260.40
|
| Rate for Payer: Health Management Network Commercial |
$316.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$189.72
|
| Rate for Payer: MDX Hawaii PPO |
$360.84
|
| Rate for Payer: University Health Alliance Commercial |
$208.32
|
|
|
WASHER WIRE FORM WASHR
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$283.36 |
| Max. Negotiated Rate |
$490.82 |
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$354.20
|
| Rate for Payer: Health Management Network Commercial |
$430.10
|
| Rate for Payer: MDX Hawaii PPO |
$490.82
|
| Rate for Payer: University Health Alliance Commercial |
$283.36
|
|
|
WASHER WIRE FORM WASHR
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$258.06 |
| Max. Negotiated Rate |
$490.82 |
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$354.20
|
| Rate for Payer: Health Management Network Commercial |
$430.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$318.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$258.06
|
| Rate for Payer: MDX Hawaii PPO |
$490.82
|
| Rate for Payer: University Health Alliance Commercial |
$283.36
|
|
|
WASHR SPIKE 13.5/4.0MM 219.941
|
Facility
|
OP
|
$589.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$300.39 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.30
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$371.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$300.39
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
| Rate for Payer: University Health Alliance Commercial |
$329.84
|
|
|
WASHR SPIKE 13.5/4.0MM 219.941
|
Facility
|
IP
|
$589.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$329.84 |
| Max. Negotiated Rate |
$571.33 |
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.30
|
| Rate for Payer: Health Management Network Commercial |
$500.65
|
| Rate for Payer: MDX Hawaii PPO |
$571.33
|
| Rate for Payer: University Health Alliance Commercial |
$329.84
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION [14979]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00409397701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION [14979]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00409397703
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 65219018701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 63323018507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00409488710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00409488723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00409488720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 63323018520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION [7484]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00409488717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00264785000
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264785020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264785020
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION [27834]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338001304
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
