|
TAP CORTX SCREW 3.5/110 311.32
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$449.65 |
| Max. Negotiated Rate |
$513.13 |
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Health Management Network Commercial |
$449.65
|
| Rate for Payer: MDX Hawaii PPO |
$513.13
|
|
|
TAP CORTX SCREW 3.5/110 311.32
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$269.79 |
| Max. Negotiated Rate |
$513.13 |
| Rate for Payer: Cash Price |
$317.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$502.55
|
| Rate for Payer: Health Management Network Commercial |
$449.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$269.79
|
| Rate for Payer: MDX Hawaii PPO |
$513.13
|
| Rate for Payer: University Health Alliance Commercial |
$385.59
|
|
|
TAPER M/L 6 EXT
|
Facility
|
IP
|
$10,154.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,686.24 |
| Max. Negotiated Rate |
$9,849.38 |
| Rate for Payer: Cash Price |
$6,092.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,107.80
|
| Rate for Payer: Health Management Network Commercial |
$8,630.90
|
| Rate for Payer: MDX Hawaii PPO |
$9,849.38
|
| Rate for Payer: University Health Alliance Commercial |
$5,686.24
|
|
|
TAPER M/L 6 EXT
|
Facility
|
OP
|
$10,154.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,178.54 |
| Max. Negotiated Rate |
$9,849.38 |
| Rate for Payer: Cash Price |
$6,092.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,107.80
|
| Rate for Payer: Health Management Network Commercial |
$8,630.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,397.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,178.54
|
| Rate for Payer: MDX Hawaii PPO |
$9,849.38
|
| Rate for Payer: University Health Alliance Commercial |
$5,686.24
|
|
|
TAPER POST SHLDR 8156-0032-A
|
Facility
|
IP
|
$2,436.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,364.16 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,705.20
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,364.16
|
|
|
TAPER POST SHLDR 8156-0032-A
|
Facility
|
OP
|
$2,436.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,242.36 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,705.20
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,534.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,242.36
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,364.16
|
|
|
TAP QC 2.7X100 4811-100-27
|
Facility
|
IP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
|
|
TAP QC 2.7X100 4811-100-27
|
Facility
|
OP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$378.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: University Health Alliance Commercial |
$437.34
|
|
|
TAP QC 3.5X110MM 4811-110-35
|
Facility
|
IP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.55 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
|
|
TAP QC 3.5X110MM 4811-110-35
|
Facility
|
OP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$287.13 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$534.85
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$354.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$287.13
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: University Health Alliance Commercial |
$410.37
|
|
|
TAP QC 4.0X110MM 4811-110-40
|
Facility
|
IP
|
$675.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$573.75 |
| Max. Negotiated Rate |
$654.75 |
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Health Management Network Commercial |
$573.75
|
| Rate for Payer: MDX Hawaii PPO |
$654.75
|
|
|
TAP QC 4.0X110MM 4811-110-40
|
Facility
|
OP
|
$675.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$344.25 |
| Max. Negotiated Rate |
$654.75 |
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$641.25
|
| Rate for Payer: Health Management Network Commercial |
$573.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$425.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$344.25
|
| Rate for Payer: MDX Hawaii PPO |
$654.75
|
| Rate for Payer: University Health Alliance Commercial |
$492.01
|
|
|
TARLATAMAB-DLLE 10 MG INTRAVENOUS SOLUTION [198533]
|
Facility
|
IP
|
$18,500.00
|
|
|
Service Code
|
HCPCS J9026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15,725.00 |
| Max. Negotiated Rate |
$17,945.00 |
| Rate for Payer: Cash Price |
$11,100.00
|
| Rate for Payer: Health Management Network Commercial |
$15,725.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,945.00
|
|
|
T-CLAMP FOR 2/3MM PINS M104
|
Facility
|
OP
|
$608.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$310.08 |
| Max. Negotiated Rate |
$589.76 |
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$577.60
|
| Rate for Payer: Health Management Network Commercial |
$516.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$383.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$310.08
|
| Rate for Payer: MDX Hawaii PPO |
$589.76
|
| Rate for Payer: University Health Alliance Commercial |
$443.17
|
|
|
T-CLAMP FOR 2/3MM PINS M104
|
Facility
|
IP
|
$608.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.80 |
| Max. Negotiated Rate |
$589.76 |
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Health Management Network Commercial |
$516.80
|
| Rate for Payer: MDX Hawaii PPO |
$589.76
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 67877014601
|
|
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
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268077911
|
|
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
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268077915
|
|
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
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 67877014601
|
|
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
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268077911
|
|
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
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268077915
|
|
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
|
|
|
TEMNO ACT 20X15 BIOSPY
|
Facility
|
OP
|
$234.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.34 |
| Max. Negotiated Rate |
$226.98 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$222.30
|
| Rate for Payer: Health Management Network Commercial |
$198.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$119.34
|
| Rate for Payer: MDX Hawaii PPO |
$226.98
|
| Rate for Payer: University Health Alliance Commercial |
$170.56
|
|
|
TEMNO ACT 20X15 BIOSPY
|
Facility
|
IP
|
$234.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$226.98 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Health Management Network Commercial |
$198.90
|
| Rate for Payer: MDX Hawaii PPO |
$226.98
|
|
|
TEMNO ACT 20X20 BIOSPY
|
Facility
|
OP
|
$237.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.87 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$225.15
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.87
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: University Health Alliance Commercial |
$172.75
|
|
|
TEMNO ACT 20X20 BIOSPY
|
Facility
|
IP
|
$237.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.45 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
|
