|
OXFORD UNI TIB SZ:D RM 154725
|
Facility
|
OP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,079.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,683.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD ANAT BRG LT SM SZ5
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,512.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,224.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
OXFRD ANAT BRG LT SM SZ5
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
OXFRD ANAT BRG LT SM SZ6
|
Facility
|
OP
|
$2,880.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,468.80 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,016.00
|
| Rate for Payer: Health Management Network Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,814.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,468.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,793.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,612.80
|
|
|
OXFRD ANAT BRG LT SM SZ6
|
Facility
|
IP
|
$2,880.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.80 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,016.00
|
| Rate for Payer: Health Management Network Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,793.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,612.80
|
|
|
OXFRD ANAT BRG RT LG SZ4
|
Facility
|
OP
|
$2,649.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,350.99 |
| Max. Negotiated Rate |
$2,569.53 |
| Rate for Payer: Cash Price |
$1,589.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,854.30
|
| Rate for Payer: Health Management Network Commercial |
$2,251.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,668.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,350.99
|
| Rate for Payer: MDX Hawaii PPO |
$2,569.53
|
| Rate for Payer: University Health Alliance Commercial |
$1,483.44
|
|
|
OXFRD ANAT BRG RT LG SZ4
|
Facility
|
IP
|
$2,649.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,483.44 |
| Max. Negotiated Rate |
$2,569.53 |
| Rate for Payer: Cash Price |
$1,589.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,854.30
|
| Rate for Payer: Health Management Network Commercial |
$2,251.65
|
| Rate for Payer: MDX Hawaii PPO |
$2,569.53
|
| Rate for Payer: University Health Alliance Commercial |
$1,483.44
|
|
|
OXFRD UNI TIB SZ:B LM 154720
|
Facility
|
IP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,848.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:B LM 154720
|
Facility
|
OP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,079.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,683.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:B RM 154721
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,708.50 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,110.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,708.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXFRD UNI TIB SZ:B RM 154721
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,876.00 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXFRD UNI TIB SZ:C RM 154723
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,876.00 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXFRD UNI TIB SZ:C RM 154723
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,708.50 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,110.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,708.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXFRD UNI TIB SZ:D LM 154724
|
Facility
|
IP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,848.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:D LM 154724
|
Facility
|
OP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,079.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,683.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:E RM 154727
|
Facility
|
OP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,079.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,683.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:E RM 154727
|
Facility
|
IP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,848.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
|
OXFRD UNI TIB SZ:F RM 154776
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,876.00 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXFRD UNI TIB SZ:F RM 154776
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,708.50 |
| Max. Negotiated Rate |
$3,249.50 |
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,345.00
|
| Rate for Payer: Health Management Network Commercial |
$2,847.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,110.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,708.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,249.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,876.00
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 10702020101
|
|
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
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687067011
|
|
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
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687067001
|
|
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
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 10702020101
|
|
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
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687067011
|
|
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
|
|
|
OXYBUTYNIN CHLORIDE 5 MG TABLET [5938]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687067001
|
|
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
|
|
