|
ACCOLADE MRI DR IS-1 L311
|
Facility
|
IP
|
$8,064.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$4,515.84 |
| Max. Negotiated Rate |
$7,822.08 |
| Rate for Payer: Cash Price |
$4,838.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,644.80
|
| Rate for Payer: Health Management Network Commercial |
$6,854.40
|
| Rate for Payer: MDX Hawaii PPO |
$7,822.08
|
| Rate for Payer: University Health Alliance Commercial |
$4,515.84
|
|
|
ACCOLADE MRI DR IS-1 L311
|
Facility
|
OP
|
$8,064.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$4,112.64 |
| Max. Negotiated Rate |
$7,822.08 |
| Rate for Payer: Cash Price |
$4,838.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,644.80
|
| Rate for Payer: Health Management Network Commercial |
$6,854.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,080.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,112.64
|
| Rate for Payer: MDX Hawaii PPO |
$7,822.08
|
| Rate for Payer: University Health Alliance Commercial |
$4,515.84
|
|
|
ACETABULAR LINER 1221-36-056
|
Facility
|
IP
|
$4,078.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,283.68 |
| Max. Negotiated Rate |
$3,955.66 |
| Rate for Payer: Cash Price |
$2,446.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,854.60
|
| Rate for Payer: Health Management Network Commercial |
$3,466.30
|
| Rate for Payer: MDX Hawaii PPO |
$3,955.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,283.68
|
|
|
ACETABULAR LINER 1221-36-056
|
Facility
|
OP
|
$4,078.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,079.78 |
| Max. Negotiated Rate |
$3,955.66 |
| Rate for Payer: Cash Price |
$2,446.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,854.60
|
| Rate for Payer: Health Management Network Commercial |
$3,466.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,569.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,079.78
|
| Rate for Payer: MDX Hawaii PPO |
$3,955.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,283.68
|
|
|
ACETABULAR LINER 36MM 30103606
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,020.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,260.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
ACETABULAR LINER 36MM 30103606
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
ACETABULAR SHELL 1217-32-056
|
Facility
|
IP
|
$6,392.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,579.52 |
| Max. Negotiated Rate |
$6,200.24 |
| Rate for Payer: Cash Price |
$3,835.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,474.40
|
| Rate for Payer: Health Management Network Commercial |
$5,433.20
|
| Rate for Payer: MDX Hawaii PPO |
$6,200.24
|
| Rate for Payer: University Health Alliance Commercial |
$3,579.52
|
|
|
ACETABULAR SHELL 1217-32-056
|
Facility
|
OP
|
$6,392.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,259.92 |
| Max. Negotiated Rate |
$6,200.24 |
| Rate for Payer: Cash Price |
$3,835.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,474.40
|
| Rate for Payer: Health Management Network Commercial |
$5,433.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,026.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,259.92
|
| Rate for Payer: MDX Hawaii PPO |
$6,200.24
|
| Rate for Payer: University Health Alliance Commercial |
$3,579.52
|
|
|
ACETABULAR SHELL 50 709-04-50D
|
Facility
|
IP
|
$6,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,518.48 |
| Max. Negotiated Rate |
$6,094.51 |
| Rate for Payer: Cash Price |
$3,769.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,398.10
|
| Rate for Payer: Health Management Network Commercial |
$5,340.55
|
| Rate for Payer: MDX Hawaii PPO |
$6,094.51
|
| Rate for Payer: University Health Alliance Commercial |
$3,518.48
|
|
|
ACETABULAR SHELL 50 709-04-50D
|
Facility
|
OP
|
$6,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,204.33 |
| Max. Negotiated Rate |
$6,094.51 |
| Rate for Payer: Cash Price |
$3,769.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,398.10
|
| Rate for Payer: Health Management Network Commercial |
$5,340.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,958.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,204.33
|
| Rate for Payer: MDX Hawaii PPO |
$6,094.51
|
| Rate for Payer: University Health Alliance Commercial |
$3,518.48
|
|
|
ACETABULAR SHELL 709-04-48D
|
Facility
|
OP
|
$6,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,204.33 |
| Max. Negotiated Rate |
$6,094.51 |
| Rate for Payer: Cash Price |
$3,769.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,398.10
|
| Rate for Payer: Health Management Network Commercial |
$5,340.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,958.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,204.33
|
| Rate for Payer: MDX Hawaii PPO |
$6,094.51
|
| Rate for Payer: University Health Alliance Commercial |
$3,518.48
|
|
|
ACETABULAR SHELL 709-04-48D
|
Facility
|
IP
|
$6,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,518.48 |
| Max. Negotiated Rate |
$6,094.51 |
| Rate for Payer: Cash Price |
$3,769.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,398.10
|
| Rate for Payer: Health Management Network Commercial |
$5,340.55
|
| Rate for Payer: MDX Hawaii PPO |
$6,094.51
|
| Rate for Payer: University Health Alliance Commercial |
$3,518.48
|
|
|
ACETABULAR WEDGE 5096-4615
|
Facility
|
IP
|
$4,378.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,451.68 |
| Max. Negotiated Rate |
$4,246.66 |
| Rate for Payer: Cash Price |
$2,626.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,064.60
|
| Rate for Payer: Health Management Network Commercial |
$3,721.30
|
| Rate for Payer: MDX Hawaii PPO |
$4,246.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,451.68
|
|
|
ACETABULAR WEDGE 5096-4615
|
Facility
|
OP
|
$4,378.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,232.78 |
| Max. Negotiated Rate |
$4,246.66 |
| Rate for Payer: Cash Price |
$2,626.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,064.60
|
| Rate for Payer: Health Management Network Commercial |
$3,721.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,758.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,232.78
|
| Rate for Payer: MDX Hawaii PPO |
$4,246.66
|
| Rate for Payer: University Health Alliance Commercial |
$2,451.68
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J0134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [108021]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J0134
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 45802073200
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 45802073230
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51672211500
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802073200
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802073230
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51672211502
|
|
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
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [103]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51672211500
|
|
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
|
|
