|
CUP FUSION 7HOLE 14MM FC07
|
Facility
|
IP
|
$2,780.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.80 |
| Max. Negotiated Rate |
$2,696.60 |
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,946.00
|
| Rate for Payer: Health Management Network Commercial |
$2,363.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,696.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,556.80
|
|
|
CUP FUSION 7HOLE 14MM FC07
|
Facility
|
OP
|
$2,780.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.80 |
| Max. Negotiated Rate |
$2,696.60 |
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,946.00
|
| Rate for Payer: Health Management Network Commercial |
$2,363.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,751.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,417.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,696.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,556.80
|
|
|
CUP HUMERAL 32X4MM 5570-3204
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.00 |
| Max. Negotiated Rate |
$3,880.00 |
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,800.00
|
| Rate for Payer: Health Management Network Commercial |
$3,400.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,880.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,240.00
|
|
|
CUP HUMERAL 32X4MM 5570-3204
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.00 |
| Max. Negotiated Rate |
$3,880.00 |
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,800.00
|
| Rate for Payer: Health Management Network Commercial |
$3,400.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,520.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,040.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,880.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,240.00
|
|
|
CUP SUTURE 36 AR-9502F-36CPC
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,820.70 |
| Max. Negotiated Rate |
$3,462.90 |
| Rate for Payer: Cash Price |
$2,142.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,499.00
|
| Rate for Payer: Health Management Network Commercial |
$3,034.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,249.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,820.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,462.90
|
| Rate for Payer: University Health Alliance Commercial |
$1,999.20
|
|
|
CUP SUTURE 36 AR-9502F-36CPC
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,999.20 |
| Max. Negotiated Rate |
$3,462.90 |
| Rate for Payer: Cash Price |
$2,142.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,499.00
|
| Rate for Payer: Health Management Network Commercial |
$3,034.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,462.90
|
| Rate for Payer: University Health Alliance Commercial |
$1,999.20
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$6,743.44
|
|
|
Service Code
|
CPT 59160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,743.44 |
| Rate for Payer: AlohaCare Medicaid |
$3,824.16
|
| Rate for Payer: AlohaCare Medicare |
$3,824.16
|
| Rate for Payer: Devoted Health Medicare |
$4,206.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,824.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$3,824.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,824.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,206.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,824.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,824.16
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
CUTTER KNOT PUSHER #AR-4515
|
Facility
|
IP
|
$492.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$418.20 |
| Max. Negotiated Rate |
$477.24 |
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Health Management Network Commercial |
$418.20
|
| Rate for Payer: MDX Hawaii PPO |
$477.24
|
|
|
CUTTER KNOT PUSHER #AR-4515
|
Facility
|
OP
|
$492.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.92 |
| Max. Negotiated Rate |
$477.24 |
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$467.40
|
| Rate for Payer: Health Management Network Commercial |
$418.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$250.92
|
| Rate for Payer: MDX Hawaii PPO |
$477.24
|
| Rate for Payer: University Health Alliance Commercial |
$358.62
|
|
|
CUTTER SUTURE TENSION AR-5815
|
Facility
|
IP
|
$656.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$557.60 |
| Max. Negotiated Rate |
$636.32 |
| Rate for Payer: Cash Price |
$393.60
|
| Rate for Payer: Health Management Network Commercial |
$557.60
|
| Rate for Payer: MDX Hawaii PPO |
$636.32
|
|
|
CUTTER SUTURE TENSION AR-5815
|
Facility
|
OP
|
$656.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$334.56 |
| Max. Negotiated Rate |
$636.32 |
| Rate for Payer: Cash Price |
$393.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$623.20
|
| Rate for Payer: Health Management Network Commercial |
$557.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$413.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$334.56
|
| Rate for Payer: MDX Hawaii PPO |
$636.32
|
| Rate for Payer: University Health Alliance Commercial |
$478.16
|
|
|
CVA & PRECEREBRAL OCCLUSION W INFARCT
|
Facility
|
IP
|
$4,740.10
|
|
|
Service Code
|
APR-DRG 0452
|
| Min. Negotiated Rate |
$4,740.10 |
| Max. Negotiated Rate |
$4,740.10 |
| Rate for Payer: AlohaCare Medicaid |
$4,740.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,740.10
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,740.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,740.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,740.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,740.10
|
|
|
CVA & PRECEREBRAL OCCLUSION W INFARCT
|
Facility
|
IP
|
$3,933.23
|
|
|
Service Code
|
APR-DRG 0451
|
| Min. Negotiated Rate |
$3,933.23 |
| Max. Negotiated Rate |
$3,933.23 |
| Rate for Payer: AlohaCare Medicaid |
$3,933.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,933.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,933.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,933.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,933.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,933.23
|
|
|
CVA & PRECEREBRAL OCCLUSION W INFARCT
|
Facility
|
IP
|
$6,504.51
|
|
|
Service Code
|
APR-DRG 0453
|
| Min. Negotiated Rate |
$6,504.51 |
| Max. Negotiated Rate |
$6,504.51 |
| Rate for Payer: AlohaCare Medicaid |
$6,504.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6,504.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6,504.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,504.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,504.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,504.51
|
|
|
CVA & PRECEREBRAL OCCLUSION W INFARCT
|
Facility
|
IP
|
$10,416.86
|
|
|
Service Code
|
APR-DRG 0454
|
| Min. Negotiated Rate |
$10,416.86 |
| Max. Negotiated Rate |
$10,416.86 |
| Rate for Payer: AlohaCare Medicaid |
$10,416.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10,416.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10,416.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,416.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,416.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,416.86
|
|
|
CXP PRECONNECT TENACIO 21CM
|
Facility
|
IP
|
$29,515.00
|
|
|
Service Code
|
HCPCS C1813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,528.40 |
| Max. Negotiated Rate |
$28,629.55 |
| Rate for Payer: Cash Price |
$17,709.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,660.50
|
| Rate for Payer: Health Management Network Commercial |
$25,087.75
|
| Rate for Payer: MDX Hawaii PPO |
$28,629.55
|
| Rate for Payer: University Health Alliance Commercial |
$16,528.40
|
|
|
CXP PRECONNECT TENACIO 21CM
|
Facility
|
OP
|
$29,515.00
|
|
|
Service Code
|
HCPCS C1813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15,052.65 |
| Max. Negotiated Rate |
$28,629.55 |
| Rate for Payer: Cash Price |
$17,709.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,660.50
|
| Rate for Payer: Health Management Network Commercial |
$25,087.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$18,594.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15,052.65
|
| Rate for Payer: MDX Hawaii PPO |
$28,629.55
|
| Rate for Payer: University Health Alliance Commercial |
$16,528.40
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687055801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687055811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687055811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 69097084607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 69097084607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687055801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
