|
DRSG SM VAC PEEL
|
Facility
|
OP
|
$377.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.50 |
| Max. Negotiated Rate |
$365.69 |
| Rate for Payer: AlohaCare Medicaid |
$188.50
|
| Rate for Payer: AlohaCare Medicare |
$286.52
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Devoted Health Medicare |
$316.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$286.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$358.15
|
| Rate for Payer: Health Management Network Commercial |
$320.45
|
| Rate for Payer: Humana Medicare |
$286.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$192.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$286.52
|
| Rate for Payer: MDX Hawaii PPO |
$365.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$286.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$286.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$286.52
|
| Rate for Payer: University Health Alliance Commercial |
$274.80
|
|
|
DRSG SM VAC PEEL
|
Facility
|
IP
|
$377.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$320.45 |
| Max. Negotiated Rate |
$365.69 |
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Health Management Network Commercial |
$320.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.30
|
| Rate for Payer: MDX Hawaii PPO |
$365.69
|
|
|
DRSG SURGICEL 3X2
|
Facility
|
OP
|
$255.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$247.35 |
| Rate for Payer: AlohaCare Medicaid |
$127.50
|
| Rate for Payer: AlohaCare Medicare |
$193.80
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Devoted Health Medicare |
$214.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$193.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$242.25
|
| Rate for Payer: Health Management Network Commercial |
$216.75
|
| Rate for Payer: Humana Medicare |
$193.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$130.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$193.80
|
| Rate for Payer: MDX Hawaii PPO |
$247.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$193.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$193.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$193.80
|
| Rate for Payer: University Health Alliance Commercial |
$185.87
|
|
|
DRSG SURGICEL 3X2
|
Facility
|
IP
|
$255.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$216.75 |
| Max. Negotiated Rate |
$247.35 |
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Health Management Network Commercial |
$216.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$229.50
|
| Rate for Payer: MDX Hawaii PPO |
$247.35
|
|
|
DRSG SURGICEL 4X8
|
Facility
|
IP
|
$432.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$367.20 |
| Max. Negotiated Rate |
$419.04 |
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Health Management Network Commercial |
$367.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$388.80
|
| Rate for Payer: MDX Hawaii PPO |
$419.04
|
|
|
DRSG SURGICEL 4X8
|
Facility
|
OP
|
$432.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$419.04 |
| Rate for Payer: AlohaCare Medicaid |
$216.00
|
| Rate for Payer: AlohaCare Medicare |
$328.32
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Devoted Health Medicare |
$362.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$328.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$410.40
|
| Rate for Payer: Health Management Network Commercial |
$367.20
|
| Rate for Payer: Humana Medicare |
$328.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$388.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$220.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$328.32
|
| Rate for Payer: MDX Hawaii PPO |
$419.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$328.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$328.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$328.32
|
| Rate for Payer: University Health Alliance Commercial |
$314.88
|
|
|
DRSG SURGICEL .5X2
|
Facility
|
IP
|
$165.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$140.25 |
| Max. Negotiated Rate |
$160.05 |
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Health Management Network Commercial |
$140.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.50
|
| Rate for Payer: MDX Hawaii PPO |
$160.05
|
|
|
DRSG SURGICEL .5X2
|
Facility
|
OP
|
$165.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$160.05 |
| Rate for Payer: AlohaCare Medicaid |
$82.50
|
| Rate for Payer: AlohaCare Medicare |
$125.40
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Devoted Health Medicare |
$138.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$125.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$156.75
|
| Rate for Payer: Health Management Network Commercial |
$140.25
|
| Rate for Payer: Humana Medicare |
$125.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$125.40
|
| Rate for Payer: MDX Hawaii PPO |
$160.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$125.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$125.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$125.40
|
| Rate for Payer: University Health Alliance Commercial |
$120.27
|
|
|
DRSG WOUND VAC LG
|
Facility
|
OP
|
$208.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$201.76 |
| Rate for Payer: AlohaCare Medicaid |
$104.00
|
| Rate for Payer: AlohaCare Medicare |
$158.08
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Devoted Health Medicare |
$174.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$197.60
|
| Rate for Payer: Health Management Network Commercial |
$176.80
|
| Rate for Payer: Humana Medicare |
$158.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$187.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$106.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.08
|
| Rate for Payer: MDX Hawaii PPO |
$201.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.08
|
| Rate for Payer: University Health Alliance Commercial |
$151.61
|
|
|
DRSG WOUND VAC LG
|
Facility
|
IP
|
$208.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$176.80 |
| Max. Negotiated Rate |
$201.76 |
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Health Management Network Commercial |
$176.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$187.20
|
| Rate for Payer: MDX Hawaii PPO |
$201.76
|
|
|
DRSG WOUND VAC MED
|
Facility
|
IP
|
$211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.35 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.90
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
|
|
DRSG WOUND VAC MED
|
Facility
|
OP
|
$211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.50 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: AlohaCare Medicaid |
$105.50
|
| Rate for Payer: AlohaCare Medicare |
$160.36
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Devoted Health Medicare |
$177.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$200.45
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: Humana Medicare |
$160.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.36
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.36
|
| Rate for Payer: University Health Alliance Commercial |
$153.80
|
|
|
DRSG WOUND VAC SM
|
Facility
|
OP
|
$171.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$165.87 |
| Rate for Payer: AlohaCare Medicaid |
$85.50
|
| Rate for Payer: AlohaCare Medicare |
$129.96
|
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Devoted Health Medicare |
$143.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$129.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$162.45
|
| Rate for Payer: Health Management Network Commercial |
$145.35
|
| Rate for Payer: Humana Medicare |
$129.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$129.96
|
| Rate for Payer: MDX Hawaii PPO |
$165.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$129.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$129.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$129.96
|
| Rate for Payer: University Health Alliance Commercial |
$124.64
|
|
|
DRSG WOUND VAC SM
|
Facility
|
IP
|
$171.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$145.35 |
| Max. Negotiated Rate |
$165.87 |
| Rate for Payer: Cash Price |
$102.60
|
| Rate for Payer: Health Management Network Commercial |
$145.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.90
|
| Rate for Payer: MDX Hawaii PPO |
$165.87
|
|
|
DUALKNIFE J UPPER LGTH KD-655L
|
Facility
|
IP
|
$2,909.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,472.65 |
| Max. Negotiated Rate |
$2,821.73 |
| Rate for Payer: Cash Price |
$1,745.40
|
| Rate for Payer: Health Management Network Commercial |
$2,472.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,618.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,821.73
|
|
|
DUALKNIFE J UPPER LGTH KD-655L
|
Facility
|
OP
|
$2,909.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,454.50 |
| Max. Negotiated Rate |
$2,821.73 |
| Rate for Payer: AlohaCare Medicaid |
$1,454.50
|
| Rate for Payer: AlohaCare Medicare |
$2,210.84
|
| Rate for Payer: Cash Price |
$1,745.40
|
| Rate for Payer: Devoted Health Medicare |
$2,443.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,210.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,763.55
|
| Rate for Payer: Health Management Network Commercial |
$2,472.65
|
| Rate for Payer: Humana Medicare |
$2,210.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,618.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,483.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,210.84
|
| Rate for Payer: MDX Hawaii PPO |
$2,821.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,210.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,210.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,210.84
|
| Rate for Payer: University Health Alliance Commercial |
$2,120.37
|
|
|
DUAL PORT COAXIAL INTRO KIT
|
Facility
|
OP
|
$1,365.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$682.50 |
| Max. Negotiated Rate |
$1,324.05 |
| Rate for Payer: AlohaCare Medicaid |
$682.50
|
| Rate for Payer: AlohaCare Medicare |
$1,037.40
|
| Rate for Payer: Cash Price |
$819.00
|
| Rate for Payer: Devoted Health Medicare |
$1,146.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,037.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,296.75
|
| Rate for Payer: Health Management Network Commercial |
$1,160.25
|
| Rate for Payer: Humana Medicare |
$1,037.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,228.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$696.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,037.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,324.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,037.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,037.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,037.40
|
| Rate for Payer: University Health Alliance Commercial |
$994.95
|
|
|
DUAL PORT COAXIAL INTRO KIT
|
Facility
|
IP
|
$1,365.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,160.25 |
| Max. Negotiated Rate |
$1,324.05 |
| Rate for Payer: Cash Price |
$819.00
|
| Rate for Payer: Health Management Network Commercial |
$1,160.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,228.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,324.05
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687072311
|
|
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: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00904704304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 68084067521
|
|
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: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 68084067521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00904704304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 27241009706
|
|
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: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687072311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
