|
MESH VENTRALEX SMALL 5950007
|
Facility
|
OP
|
$2,280.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.80 |
| Max. Negotiated Rate |
$2,211.60 |
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,596.00
|
| Rate for Payer: Health Management Network Commercial |
$1,938.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,436.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,162.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,211.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,276.80
|
|
|
MESH VENTRALEX SMALL 5950007
|
Facility
|
IP
|
$2,280.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,276.80 |
| Max. Negotiated Rate |
$2,211.60 |
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,596.00
|
| Rate for Payer: Health Management Network Commercial |
$1,938.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,211.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,276.80
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS J9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.85
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.13
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.80
|
| Rate for Payer: University Health Alliance Commercial |
$45.92
|
| Rate for Payer: University Health Alliance Commercial |
$76.53
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J9209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$61.11 |
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
|
|
METACARPOPHALANGEAL 5800-MD00
|
Facility
|
IP
|
$7,650.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,284.00 |
| Max. Negotiated Rate |
$7,420.50 |
| Rate for Payer: Cash Price |
$4,590.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,355.00
|
| Rate for Payer: Health Management Network Commercial |
$6,502.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,420.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,284.00
|
|
|
METACARPOPHALANGEAL 5800-MD00
|
Facility
|
OP
|
$7,650.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,901.50 |
| Max. Negotiated Rate |
$7,420.50 |
| Rate for Payer: Cash Price |
$4,590.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,355.00
|
| Rate for Payer: Health Management Network Commercial |
$6,502.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,819.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,901.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,420.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,284.00
|
|
|
METER COIL ERICH ARCH 6001303
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$116.28 |
| Max. Negotiated Rate |
$221.16 |
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$193.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$143.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$116.28
|
| Rate for Payer: MDX Hawaii PPO |
$221.16
|
| Rate for Payer: University Health Alliance Commercial |
$127.68
|
|
|
METER COIL ERICH ARCH 6001303
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.68 |
| Max. Negotiated Rate |
$221.16 |
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$193.80
|
| Rate for Payer: MDX Hawaii PPO |
$221.16
|
| Rate for Payer: University Health Alliance Commercial |
$127.68
|
|
|
METFORMIN 1,000 MG TABLET [24398]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 70010006501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
METFORMIN 1,000 MG TABLET [24398]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 70010006501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
METFORMIN 500 MG TABLET [10544]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904716261
|
|
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
|
|
|
METFORMIN 500 MG TABLET [10544]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904716261
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 70010006401
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687014301
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 70010006401
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687014301
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687014311
|
|
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
|
|
|
METFORMIN 850 MG TABLET [14719]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687014311
|
|
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
|
|
|
METHACHOLINE 0 MG TO 48 MG/3 ML (0 MG TO 16 MG/ML) NEBULIZATION SOLN [174646]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J7674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.80 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
|
|
METHACHOLINE 0 MG TO 48 MG/3 ML (0 MG TO 16 MG/ML) NEBULIZATION SOLN [174646]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS J7674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.60
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.68
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.80
|
| Rate for Payer: University Health Alliance Commercial |
$49.57
|
|
|
METHACHOLINE CHLORIDE 0.1875 MG/3 ML (0.0625 MG/ML) NEBULIZATION SOLN [209711]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 64281011200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
METHACHOLINE CHLORIDE 0.75 MG/3 ML (0.25 MG/ML) NEBULIZATION SOLUTION [209712]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 64281011300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
METHACHOLINE CHLORIDE 0 MG/3 ML (0 MG/ML) NEBULIZATION SOLUTION [209732]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 64281011100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
METHACHOLINE CHLORIDE 12 MG/3 ML (4 MG/ML) NEBULIZATION SOLUTION [209709]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 64281011500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
METHACHOLINE CHLORIDE 3 MG/3 ML (1 MG/ML) NEBULIZATION SOLUTION [209708]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 64281011400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
