|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [129454]
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS Q5101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE [129454]
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS Q5101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$601.16
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$664.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$601.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$601.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$403.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$601.16
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$601.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$601.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$474.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$601.16
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
FILTER LEUKOCYT PALL
|
Facility
|
OP
|
$96.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: AlohaCare Medicaid |
$48.00
|
| Rate for Payer: AlohaCare Medicare |
$72.96
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Devoted Health Medicare |
$80.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.20
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Humana Medicare |
$72.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.96
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.96
|
| Rate for Payer: University Health Alliance Commercial |
$69.97
|
|
|
FILTER LEUKOCYT PALL
|
Facility
|
IP
|
$96.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.40
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
|
|
FILTER PLATELTS PALL
|
Facility
|
IP
|
$157.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$133.45 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
|
|
FILTER PLATELTS PALL
|
Facility
|
OP
|
$157.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.50 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$119.32
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Devoted Health Medicare |
$131.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$119.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.15
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$119.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.32
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.32
|
| Rate for Payer: University Health Alliance Commercial |
$114.44
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 50268031415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687042811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687042801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687042811
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687042865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687042865
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687042801
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
FINASTERIDE 5 MG TABLET [10037]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 50268031415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$8.36
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$9.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$8.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.36
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.36
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
FINELINE LEAD AV 45CM 4469
|
Facility
|
IP
|
$1,815.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,016.40 |
| Max. Negotiated Rate |
$1,760.55 |
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,270.50
|
| Rate for Payer: Health Management Network Commercial |
$1,542.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,633.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,760.55
|
| Rate for Payer: University Health Alliance Commercial |
$1,016.40
|
|
|
FINELINE LEAD AV 45CM 4469
|
Facility
|
OP
|
$1,815.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$907.50 |
| Max. Negotiated Rate |
$1,760.55 |
| Rate for Payer: AlohaCare Medicaid |
$907.50
|
| Rate for Payer: AlohaCare Medicare |
$1,379.40
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Devoted Health Medicare |
$1,524.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,379.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,270.50
|
| Rate for Payer: Health Management Network Commercial |
$1,542.75
|
| Rate for Payer: Humana Medicare |
$1,379.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,633.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$925.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,379.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,760.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,379.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,379.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,379.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,016.40
|
|
|
FINELINE LEAD AV 52CM 4470
|
Facility
|
OP
|
$1,815.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$907.50 |
| Max. Negotiated Rate |
$1,760.55 |
| Rate for Payer: AlohaCare Medicaid |
$907.50
|
| Rate for Payer: AlohaCare Medicare |
$1,379.40
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Devoted Health Medicare |
$1,524.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,379.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,270.50
|
| Rate for Payer: Health Management Network Commercial |
$1,542.75
|
| Rate for Payer: Humana Medicare |
$1,379.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,633.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$925.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,379.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,760.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,379.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,379.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,379.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,016.40
|
|
|
FINELINE LEAD AV 52CM 4470
|
Facility
|
IP
|
$1,815.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,016.40 |
| Max. Negotiated Rate |
$1,760.55 |
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,270.50
|
| Rate for Payer: Health Management Network Commercial |
$1,542.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,633.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,760.55
|
| Rate for Payer: University Health Alliance Commercial |
$1,016.40
|
|
|
FINELINE LEAD STEROX 4457
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| 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: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
FINELINE LEAD STEROX 4457
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,200.00
|
| Rate for Payer: AlohaCare Medicare |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Devoted Health Medicare |
$2,016.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,824.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Humana Medicare |
$1,824.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,224.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,824.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,824.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,824.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,824.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
FIXATION DEVICE 5MM 174006
|
Facility
|
IP
|
$2,260.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,921.00 |
| Max. Negotiated Rate |
$2,192.20 |
| Rate for Payer: Cash Price |
$1,356.00
|
| Rate for Payer: Health Management Network Commercial |
$1,921.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,034.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,192.20
|
|
|
FIXATION DEVICE 5MM 174006
|
Facility
|
OP
|
$2,260.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,130.00 |
| Max. Negotiated Rate |
$2,192.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,130.00
|
| Rate for Payer: AlohaCare Medicare |
$1,717.60
|
| Rate for Payer: Cash Price |
$1,356.00
|
| Rate for Payer: Devoted Health Medicare |
$1,898.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,717.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,147.00
|
| Rate for Payer: Health Management Network Commercial |
$1,921.00
|
| Rate for Payer: Humana Medicare |
$1,717.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,034.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,152.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,717.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,192.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,717.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,717.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,717.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,647.31
|
|
|
FIXATION KIT ACL/PCL AR-1593
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$1,746.00 |
| Rate for Payer: AlohaCare Medicaid |
$900.00
|
| Rate for Payer: AlohaCare Medicare |
$1,368.00
|
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Devoted Health Medicare |
$1,512.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,368.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,260.00
|
| Rate for Payer: Health Management Network Commercial |
$1,530.00
|
| Rate for Payer: Humana Medicare |
$1,368.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,620.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$918.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,368.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,746.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,368.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,368.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,368.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,008.00
|
|
|
FIXATION KIT ACL/PCL AR-1593
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,008.00 |
| Max. Negotiated Rate |
$1,746.00 |
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,260.00
|
| Rate for Payer: Health Management Network Commercial |
$1,530.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,620.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,746.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,008.00
|
|
|
FIXATION SECONDARY AR-1593-P
|
Facility
|
OP
|
$2,284.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,142.00 |
| Max. Negotiated Rate |
$2,215.48 |
| Rate for Payer: AlohaCare Medicaid |
$1,142.00
|
| Rate for Payer: AlohaCare Medicare |
$1,735.84
|
| Rate for Payer: Cash Price |
$1,370.40
|
| Rate for Payer: Devoted Health Medicare |
$1,918.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,735.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,598.80
|
| Rate for Payer: Health Management Network Commercial |
$1,941.40
|
| Rate for Payer: Humana Medicare |
$1,735.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,055.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,164.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,735.84
|
| Rate for Payer: MDX Hawaii PPO |
$2,215.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,735.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,735.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,735.84
|
| Rate for Payer: University Health Alliance Commercial |
$1,279.04
|
|
