|
RANGER DCB 6X60X135
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,230.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,142.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,734.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,478.26
|
|
|
RANGER DCB 6X60X135
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,890.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
|
|
RANGER DCB 6X80X135
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,890.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
|
|
RANGER DCB 6X80X135
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,230.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,142.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,734.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,478.26
|
|
|
RANGER DCB 7X120X150
|
Facility
|
IP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,051.50 |
| Max. Negotiated Rate |
$3,482.30 |
| Rate for Payer: Cash Price |
$2,154.00
|
| Rate for Payer: Health Management Network Commercial |
$3,051.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,482.30
|
|
|
RANGER DCB 7X120X150
|
Facility
|
OP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,830.90 |
| Max. Negotiated Rate |
$3,482.30 |
| Rate for Payer: Cash Price |
$2,154.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,410.50
|
| Rate for Payer: Health Management Network Commercial |
$3,051.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,261.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,830.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,482.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,616.75
|
|
|
RANGER DCB 7X200X150
|
Facility
|
IP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,740.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
|
|
RANGER DCB 7X200X150
|
Facility
|
OP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,244.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,180.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,772.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,244.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,207.16
|
|
|
RANGER DCB 7X40X135
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,230.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,142.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,734.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,478.26
|
|
|
RANGER DCB 7X40X135
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,890.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
|
|
RANGER DCB 7X60X135
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,890.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
|
|
RANGER DCB 7X60X135
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,230.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,142.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,734.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,478.26
|
|
|
RANGER DCB 7X80X135
|
Facility
|
IP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,890.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
|
|
RANGER DCB 7X80X135
|
Facility
|
OP
|
$3,400.00
|
|
|
Service Code
|
HCPCS C2623
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,734.00 |
| Max. Negotiated Rate |
$3,298.00 |
| Rate for Payer: Cash Price |
$2,040.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,230.00
|
| Rate for Payer: Health Management Network Commercial |
$2,890.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,142.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,734.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,298.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,478.26
|
|
|
RANGER IRR FLUID WMG SET 24750
|
Facility
|
OP
|
$209.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.59 |
| Max. Negotiated Rate |
$202.73 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.55
|
| Rate for Payer: Health Management Network Commercial |
$177.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$106.59
|
| Rate for Payer: MDX Hawaii PPO |
$202.73
|
| Rate for Payer: University Health Alliance Commercial |
$152.34
|
|
|
RANGER IRR FLUID WMG SET 24750
|
Facility
|
IP
|
$209.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$177.65 |
| Max. Negotiated Rate |
$202.73 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$177.65
|
| Rate for Payer: MDX Hawaii PPO |
$202.73
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 67877052560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 27241012502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 67877052560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687054921
|
|
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
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 27241012502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR [70434]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687054921
|
|
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
|
|
|
RAPID STRUT TL LONG 50-10190
|
Facility
|
IP
|
$2,633.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,238.05 |
| Max. Negotiated Rate |
$2,554.01 |
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Health Management Network Commercial |
$2,238.05
|
| Rate for Payer: MDX Hawaii PPO |
$2,554.01
|
|
|
RAPID STRUT TL LONG 50-10190
|
Facility
|
OP
|
$2,633.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,342.83 |
| Max. Negotiated Rate |
$2,554.01 |
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,501.35
|
| Rate for Payer: Health Management Network Commercial |
$2,238.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,658.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,342.83
|
| Rate for Payer: MDX Hawaii PPO |
$2,554.01
|
| Rate for Payer: University Health Alliance Commercial |
$1,919.19
|
|
|
RAPID STRUT TL LONG 50-10190CE
|
Facility
|
IP
|
$2,633.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,238.05 |
| Max. Negotiated Rate |
$2,554.01 |
| Rate for Payer: Cash Price |
$1,579.80
|
| Rate for Payer: Health Management Network Commercial |
$2,238.05
|
| Rate for Payer: MDX Hawaii PPO |
$2,554.01
|
|
