|
ALLOGRAFT 9X70MM FGL09070
|
Facility
|
IP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,787.68 |
| Max. Negotiated Rate |
$4,828.66 |
| Rate for Payer: Cash Price |
$2,986.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,484.60
|
| Rate for Payer: Health Management Network Commercial |
$4,231.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,828.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,787.68
|
|
|
ALLOGRAFT 9X70MM FGL09070
|
Facility
|
OP
|
$4,978.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,538.78 |
| Max. Negotiated Rate |
$4,828.66 |
| Rate for Payer: Cash Price |
$2,986.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,484.60
|
| Rate for Payer: Health Management Network Commercial |
$4,231.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,136.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,538.78
|
| Rate for Payer: MDX Hawaii PPO |
$4,828.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,787.68
|
|
|
ALLOGRAFT DERMIS DML170
|
Facility
|
OP
|
$8,836.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,506.36 |
| Max. Negotiated Rate |
$8,570.92 |
| Rate for Payer: Cash Price |
$5,301.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,185.20
|
| Rate for Payer: Health Management Network Commercial |
$7,510.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,566.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,506.36
|
| Rate for Payer: MDX Hawaii PPO |
$8,570.92
|
| Rate for Payer: University Health Alliance Commercial |
$4,948.16
|
|
|
ALLOGRAFT DERMIS DML170
|
Facility
|
IP
|
$8,836.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,948.16 |
| Max. Negotiated Rate |
$8,570.92 |
| Rate for Payer: Cash Price |
$5,301.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,185.20
|
| Rate for Payer: Health Management Network Commercial |
$7,510.60
|
| Rate for Payer: MDX Hawaii PPO |
$8,570.92
|
| Rate for Payer: University Health Alliance Commercial |
$4,948.16
|
|
|
ALLOGRAFT FGL10074
|
Facility
|
IP
|
$7,040.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,942.40 |
| Max. Negotiated Rate |
$6,828.80 |
| Rate for Payer: Cash Price |
$4,224.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,928.00
|
| Rate for Payer: Health Management Network Commercial |
$5,984.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,828.80
|
| Rate for Payer: University Health Alliance Commercial |
$3,942.40
|
|
|
ALLOGRAFT FGL10074
|
Facility
|
OP
|
$7,040.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,590.40 |
| Max. Negotiated Rate |
$6,828.80 |
| Rate for Payer: Cash Price |
$4,224.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,928.00
|
| Rate for Payer: Health Management Network Commercial |
$5,984.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,435.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,590.40
|
| Rate for Payer: MDX Hawaii PPO |
$6,828.80
|
| Rate for Payer: University Health Alliance Commercial |
$3,942.40
|
|
|
ALLOGRAFT GRAFTLINK FGL09065
|
Facility
|
IP
|
$8,298.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,646.88 |
| Max. Negotiated Rate |
$8,049.06 |
| Rate for Payer: Cash Price |
$4,978.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,808.60
|
| Rate for Payer: Health Management Network Commercial |
$7,053.30
|
| Rate for Payer: MDX Hawaii PPO |
$8,049.06
|
| Rate for Payer: University Health Alliance Commercial |
$4,646.88
|
|
|
ALLOGRAFT GRAFTLINK FGL09065
|
Facility
|
OP
|
$8,298.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,231.98 |
| Max. Negotiated Rate |
$8,049.06 |
| Rate for Payer: Cash Price |
$4,978.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,808.60
|
| Rate for Payer: Health Management Network Commercial |
$7,053.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,227.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,231.98
|
| Rate for Payer: MDX Hawaii PPO |
$8,049.06
|
| Rate for Payer: University Health Alliance Commercial |
$4,646.88
|
|
|
ALLOGRAFT GRAFTLINK FGL09573
|
Facility
|
OP
|
$4,590.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,340.90 |
| Max. Negotiated Rate |
$4,452.30 |
| Rate for Payer: Cash Price |
$2,754.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,213.00
|
| Rate for Payer: Health Management Network Commercial |
$3,901.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,891.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,340.90
|
| Rate for Payer: MDX Hawaii PPO |
$4,452.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,570.40
|
|
|
ALLOGRAFT GRAFTLINK FGL09573
|
Facility
|
IP
|
$4,590.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,570.40 |
| Max. Negotiated Rate |
$4,452.30 |
| Rate for Payer: Cash Price |
$2,754.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,213.00
|
| Rate for Payer: Health Management Network Commercial |
$3,901.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,452.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,570.40
|
|
|
ALLOMAX GRAFT 7X10 #1180060
|
Facility
|
OP
|
$4,542.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,316.42 |
| Max. Negotiated Rate |
$4,405.74 |
| Rate for Payer: Cash Price |
$2,725.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,179.40
|
| Rate for Payer: Health Management Network Commercial |
$3,860.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,861.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,316.42
|
| Rate for Payer: MDX Hawaii PPO |
$4,405.74
|
| Rate for Payer: University Health Alliance Commercial |
$2,543.52
|
|
|
ALLOMAX GRAFT 7X10 #1180060
|
Facility
|
IP
|
$4,542.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,543.52 |
| Max. Negotiated Rate |
$4,405.74 |
| Rate for Payer: Cash Price |
$2,725.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,179.40
|
| Rate for Payer: Health Management Network Commercial |
$3,860.70
|
| Rate for Payer: MDX Hawaii PPO |
$4,405.74
|
| Rate for Payer: University Health Alliance Commercial |
$2,543.52
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687067701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687067701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687067711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687067711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904704161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904704161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687068801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687068801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687068811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904657261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904657261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ALLOPURINOL 300 MG TABLET [311]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687068811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
ALL-POLY PATELLA DRILL
|
Facility
|
OP
|
$1,545.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$787.95 |
| Max. Negotiated Rate |
$1,498.65 |
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,467.75
|
| Rate for Payer: Health Management Network Commercial |
$1,313.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$973.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$787.95
|
| Rate for Payer: MDX Hawaii PPO |
$1,498.65
|
| Rate for Payer: University Health Alliance Commercial |
$1,126.15
|
|
