|
ALL-POLY PATELLA DRILL
|
Facility
|
IP
|
$1,545.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,313.25 |
| Max. Negotiated Rate |
$1,498.65 |
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Health Management Network Commercial |
$1,313.25
|
| Rate for Payer: MDX Hawaii PPO |
$1,498.65
|
|
|
ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG (+/-)/20 ML IV SOLUTION [151115]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG (+/-)/20 ML IV SOLUTION [151115]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$5.14
|
| Rate for Payer: AlohaCare Medicare |
$5.14
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$5.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.19
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$5.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.14
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.14
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
ALPHAVENT 4.75MM
|
Facility
|
OP
|
$1,078.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.78 |
| Max. Negotiated Rate |
$1,045.66 |
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$754.60
|
| Rate for Payer: Health Management Network Commercial |
$916.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$679.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$549.78
|
| Rate for Payer: MDX Hawaii PPO |
$1,045.66
|
| Rate for Payer: University Health Alliance Commercial |
$603.68
|
|
|
ALPHAVENT 4.75MM
|
Facility
|
IP
|
$1,078.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$603.68 |
| Max. Negotiated Rate |
$1,045.66 |
| Rate for Payer: Cash Price |
$646.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$754.60
|
| Rate for Payer: Health Management Network Commercial |
$916.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,045.66
|
| Rate for Payer: University Health Alliance Commercial |
$603.68
|
|
|
ALPHAVENT KNOTLESS SP 4.75MM
|
Facility
|
IP
|
$1,823.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,020.88 |
| Max. Negotiated Rate |
$1,768.31 |
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,276.10
|
| Rate for Payer: Health Management Network Commercial |
$1,549.55
|
| Rate for Payer: MDX Hawaii PPO |
$1,768.31
|
| Rate for Payer: University Health Alliance Commercial |
$1,020.88
|
|
|
ALPHAVENT KNOTLESS SP 4.75MM
|
Facility
|
OP
|
$1,823.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$929.73 |
| Max. Negotiated Rate |
$1,768.31 |
| Rate for Payer: Cash Price |
$1,093.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,276.10
|
| Rate for Payer: Health Management Network Commercial |
$1,549.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,148.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$929.73
|
| Rate for Payer: MDX Hawaii PPO |
$1,768.31
|
| Rate for Payer: University Health Alliance Commercial |
$1,020.88
|
|
|
ALPHAVENT PUNCH-TAP 3910947208
|
Facility
|
OP
|
$1,728.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.28 |
| Max. Negotiated Rate |
$1,676.16 |
| Rate for Payer: Cash Price |
$1,036.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,641.60
|
| Rate for Payer: Health Management Network Commercial |
$1,468.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,088.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$881.28
|
| Rate for Payer: MDX Hawaii PPO |
$1,676.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,259.54
|
|
|
ALPHAVENT PUNCH-TAP 3910947208
|
Facility
|
IP
|
$1,728.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,468.80 |
| Max. Negotiated Rate |
$1,676.16 |
| Rate for Payer: Cash Price |
$1,036.80
|
| Rate for Payer: Health Management Network Commercial |
$1,468.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,676.16
|
|
|
ALPHAVENT TT 4.75MM 1.8X8
|
Facility
|
OP
|
$1,549.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$789.99 |
| Max. Negotiated Rate |
$1,502.53 |
| Rate for Payer: Cash Price |
$929.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,084.30
|
| Rate for Payer: Health Management Network Commercial |
$1,316.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$975.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$789.99
|
| Rate for Payer: MDX Hawaii PPO |
$1,502.53
|
| Rate for Payer: University Health Alliance Commercial |
$867.44
|
|
|
ALPHAVENT TT 4.75MM 1.8X8
|
Facility
|
IP
|
$1,549.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$867.44 |
| Max. Negotiated Rate |
$1,502.53 |
| Rate for Payer: Cash Price |
$929.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,084.30
|
| Rate for Payer: Health Management Network Commercial |
$1,316.65
|
| Rate for Payer: MDX Hawaii PPO |
$1,502.53
|
| Rate for Payer: University Health Alliance Commercial |
$867.44
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687037711
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687037711
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 59762371901
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687037701
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 59762371901
|
|
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
|
|
|
ALPRAZOLAM 0.25 MG TABLET [324]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687037701
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687038801
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687038811
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687038811
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687038801
|
|
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
|
|
|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
|
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
|
|
|
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001]
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
NDC 00009316906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.25 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
|
|
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001]
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
NDC 00009316901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.25 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
|
