|
SET IRRIG SIMPULSE SYSTEM
|
Facility
|
IP
|
$210.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$203.70 |
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
|
|
SET MINI CAP PD
|
Facility
|
OP
|
$278.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.78 |
| Max. Negotiated Rate |
$269.66 |
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$264.10
|
| Rate for Payer: Health Management Network Commercial |
$236.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$141.78
|
| Rate for Payer: MDX Hawaii PPO |
$269.66
|
| Rate for Payer: University Health Alliance Commercial |
$202.63
|
|
|
SET MINI CAP PD
|
Facility
|
IP
|
$278.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$236.30 |
| Max. Negotiated Rate |
$269.66 |
| Rate for Payer: Cash Price |
$166.80
|
| Rate for Payer: Health Management Network Commercial |
$236.30
|
| Rate for Payer: MDX Hawaii PPO |
$269.66
|
|
|
SET NIGHT DRAINAGE CONTAINER
|
Facility
|
OP
|
$143.00
|
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$72.93 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.93
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
| Rate for Payer: University Health Alliance Commercial |
$80.08
|
|
|
SET NIGHT DRAINAGE CONTAINER
|
Facility
|
IP
|
$143.00
|
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
| Rate for Payer: University Health Alliance Commercial |
$80.08
|
|
|
SET TUBE DECLOG
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$210.80 |
| Max. Negotiated Rate |
$240.56 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
|
|
SET TUBE DECLOG
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$126.48 |
| Max. Negotiated Rate |
$240.56 |
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$235.60
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$126.48
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
| Rate for Payer: University Health Alliance Commercial |
$180.77
|
|
|
SET WOUND IRRIGATION
|
Facility
|
IP
|
$87.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.95 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
|
|
SET WOUND IRRIGATION
|
Facility
|
OP
|
$87.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.37 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: University Health Alliance Commercial |
$63.41
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
NDC 33342028868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.70
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: University Health Alliance Commercial |
$33.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 00115136530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
NDC 33342028868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
NDC 65862093090
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
NDC 65862093090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.70
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: University Health Alliance Commercial |
$33.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00115136530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 50268072015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687032865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687032865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 50268072011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 50268072015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 50268072011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
SEVOFLURANE 99.97 % INHALATION LIQUID [15119]
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
NDC 66794001525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.25 |
| Max. Negotiated Rate |
$198.85 |
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Health Management Network Commercial |
$174.25
|
| Rate for Payer: MDX Hawaii PPO |
$198.85
|
|
|
SFC COMBO 24/14MM SFCBP.24/14
|
Facility
|
IP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.08 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC COMBO 24/14MM SFCBP.24/14
|
Facility
|
OP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$812.43 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,003.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$812.43
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC COMBO 27/14MM SFCBP.27/14
|
Facility
|
OP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$812.43 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,003.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$812.43
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
