|
PACK SINUS ENDOSCOPY
|
Facility
|
IP
|
$389.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.65 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
|
|
PACK SINUS ENDOSCOPY
|
Facility
|
OP
|
$389.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.50 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: AlohaCare Medicaid |
$194.50
|
| Rate for Payer: AlohaCare Medicare |
$295.64
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Devoted Health Medicare |
$326.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$295.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$369.55
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Humana Medicare |
$295.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$295.64
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$295.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$295.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$295.64
|
| Rate for Payer: University Health Alliance Commercial |
$283.54
|
|
|
PACK TOTAL JOINT
|
Facility
|
OP
|
$506.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.00 |
| Max. Negotiated Rate |
$490.82 |
| Rate for Payer: AlohaCare Medicaid |
$253.00
|
| Rate for Payer: AlohaCare Medicare |
$384.56
|
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Devoted Health Medicare |
$425.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$384.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$480.70
|
| Rate for Payer: Health Management Network Commercial |
$430.10
|
| Rate for Payer: Humana Medicare |
$384.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$455.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$258.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$384.56
|
| Rate for Payer: MDX Hawaii PPO |
$490.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$384.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$384.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$384.56
|
| Rate for Payer: University Health Alliance Commercial |
$368.82
|
|
|
PACK TOTAL JOINT
|
Facility
|
IP
|
$506.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$430.10 |
| Max. Negotiated Rate |
$490.82 |
| Rate for Payer: Cash Price |
$303.60
|
| Rate for Payer: Health Management Network Commercial |
$430.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$455.40
|
| Rate for Payer: MDX Hawaii PPO |
$490.82
|
|
|
PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS J9267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Health Management Network Commercial |
$462.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$489.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$213.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: MDX Hawaii PPO |
$527.68
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS [31025]
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
HCPCS J9267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: MDX Hawaii PPO |
$527.68
|
| Rate for Payer: AlohaCare Medicaid |
$118.50
|
| Rate for Payer: AlohaCare Medicaid |
$272.00
|
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicaid |
$59.50
|
| Rate for Payer: AlohaCare Medicare |
$90.44
|
| Rate for Payer: AlohaCare Medicare |
$106.40
|
| Rate for Payer: AlohaCare Medicare |
$180.12
|
| Rate for Payer: AlohaCare Medicare |
$413.44
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Devoted Health Medicare |
$117.60
|
| Rate for Payer: Devoted Health Medicare |
$199.08
|
| Rate for Payer: Devoted Health Medicare |
$99.96
|
| Rate for Payer: Devoted Health Medicare |
$456.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$413.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$90.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$180.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$225.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$113.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$516.80
|
| Rate for Payer: Health Management Network Commercial |
$462.40
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Humana Medicare |
$106.40
|
| Rate for Payer: Humana Medicare |
$90.44
|
| Rate for Payer: Humana Medicare |
$180.12
|
| Rate for Payer: Humana Medicare |
$413.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$213.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$489.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$277.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$413.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$180.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$90.44
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$90.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$180.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$413.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$90.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$180.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$413.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$326.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$180.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$413.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$90.44
|
| Rate for Payer: University Health Alliance Commercial |
$396.52
|
| Rate for Payer: University Health Alliance Commercial |
$172.75
|
| Rate for Payer: University Health Alliance Commercial |
$86.74
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
|
|
PACLITAXEL PROTEIN-BOUND 100 MG/20ML IV (WET SUSR VIAL) [43040475]
|
Facility
|
IP
|
$2,397.00
|
|
|
Service Code
|
HCPCS J9264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,037.45 |
| Max. Negotiated Rate |
$2,325.09 |
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Health Management Network Commercial |
$2,037.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,157.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,325.09
|
|
|
PACLITAXEL PROTEIN-BOUND 100 MG/20ML IV (WET SUSR VIAL) [43040475]
|
Facility
|
OP
|
$2,397.00
|
|
|
Service Code
|
HCPCS J9264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$2,325.09 |
| Rate for Payer: AlohaCare Medicaid |
$1,198.50
|
| Rate for Payer: AlohaCare Medicare |
$1,821.72
|
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Devoted Health Medicare |
$2,013.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,821.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,277.15
|
| Rate for Payer: Health Management Network Commercial |
$2,037.45
|
| Rate for Payer: Humana Medicare |
$1,821.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,157.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,222.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,821.72
|
| Rate for Payer: MDX Hawaii PPO |
$2,325.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,821.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,821.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,438.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,821.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,747.17
|
|
|
PACLITAXEL PROTEIN-BOUND 100 MG INTRAVENOUS SUSPENSION [40475]
|
Facility
|
OP
|
$2,397.00
|
|
|
Service Code
|
HCPCS J9264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$2,325.09 |
| Rate for Payer: AlohaCare Medicaid |
$1,198.50
|
| Rate for Payer: AlohaCare Medicaid |
$1,233.50
|
| Rate for Payer: AlohaCare Medicare |
$1,874.92
|
| Rate for Payer: AlohaCare Medicare |
$1,821.72
|
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Cash Price |
$1,480.20
|
| Rate for Payer: Cash Price |
$1,480.20
|
| Rate for Payer: Devoted Health Medicare |
$2,013.48
|
| Rate for Payer: Devoted Health Medicare |
$2,072.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,821.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,874.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,277.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,343.65
|
| Rate for Payer: Health Management Network Commercial |
$2,037.45
|
| Rate for Payer: Health Management Network Commercial |
$2,096.95
|
| Rate for Payer: Humana Medicare |
$1,821.72
|
| Rate for Payer: Humana Medicare |
$1,874.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,157.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,220.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,222.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,258.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,821.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,874.92
|
| Rate for Payer: MDX Hawaii PPO |
$2,325.09
|
| Rate for Payer: MDX Hawaii PPO |
$2,392.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,874.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,821.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,821.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,874.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,438.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,480.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,874.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,821.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,747.17
|
| Rate for Payer: University Health Alliance Commercial |
$1,798.20
|
|
|
PACLITAXEL PROTEIN-BOUND 100 MG INTRAVENOUS SUSPENSION [40475]
|
Facility
|
IP
|
$2,397.00
|
|
|
Service Code
|
HCPCS J9264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,037.45 |
| Max. Negotiated Rate |
$2,325.09 |
| Rate for Payer: Cash Price |
$1,438.20
|
| Rate for Payer: Cash Price |
$1,480.20
|
| Rate for Payer: Health Management Network Commercial |
$2,096.95
|
| Rate for Payer: Health Management Network Commercial |
$2,037.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,157.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,220.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,325.09
|
| Rate for Payer: MDX Hawaii PPO |
$2,392.99
|
|
|
PADDING CAST MOLESKIN 683640
|
Facility
|
IP
|
$215.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$182.75 |
| Max. Negotiated Rate |
$208.55 |
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Health Management Network Commercial |
$182.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.50
|
| Rate for Payer: MDX Hawaii PPO |
$208.55
|
|
|
PADDING CAST MOLESKIN 683640
|
Facility
|
OP
|
$215.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.50 |
| Max. Negotiated Rate |
$208.55 |
| Rate for Payer: AlohaCare Medicaid |
$107.50
|
| Rate for Payer: AlohaCare Medicare |
$163.40
|
| Rate for Payer: Cash Price |
$129.00
|
| Rate for Payer: Devoted Health Medicare |
$180.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$163.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$204.25
|
| Rate for Payer: Health Management Network Commercial |
$182.75
|
| Rate for Payer: Humana Medicare |
$163.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$193.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$163.40
|
| Rate for Payer: MDX Hawaii PPO |
$208.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$163.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$163.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$163.40
|
| Rate for Payer: University Health Alliance Commercial |
$156.71
|
|
|
PADS PRESSURE IMP 907-GP-10
|
Facility
|
IP
|
$239.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.15 |
| Max. Negotiated Rate |
$231.83 |
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Health Management Network Commercial |
$203.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$215.10
|
| Rate for Payer: MDX Hawaii PPO |
$231.83
|
|
|
PADS PRESSURE IMP 907-GP-10
|
Facility
|
OP
|
$239.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.50 |
| Max. Negotiated Rate |
$231.83 |
| Rate for Payer: AlohaCare Medicaid |
$119.50
|
| Rate for Payer: AlohaCare Medicare |
$181.64
|
| Rate for Payer: Cash Price |
$143.40
|
| Rate for Payer: Devoted Health Medicare |
$200.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$227.05
|
| Rate for Payer: Health Management Network Commercial |
$203.15
|
| Rate for Payer: Humana Medicare |
$181.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$215.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$121.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.64
|
| Rate for Payer: MDX Hawaii PPO |
$231.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$181.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$181.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.64
|
| Rate for Payer: University Health Alliance Commercial |
$174.21
|
|
|
PALACOS BONE CEMENT R+G
|
Facility
|
OP
|
$1,033.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$516.50 |
| Max. Negotiated Rate |
$1,002.01 |
| Rate for Payer: AlohaCare Medicaid |
$516.50
|
| Rate for Payer: AlohaCare Medicare |
$785.08
|
| Rate for Payer: Cash Price |
$619.80
|
| Rate for Payer: Devoted Health Medicare |
$867.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$785.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$723.10
|
| Rate for Payer: Health Management Network Commercial |
$878.05
|
| Rate for Payer: Humana Medicare |
$785.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$929.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$526.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$785.08
|
| Rate for Payer: MDX Hawaii PPO |
$1,002.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$785.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$785.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$785.08
|
| Rate for Payer: University Health Alliance Commercial |
$578.48
|
|
|
PALACOS BONE CEMENT R+G
|
Facility
|
IP
|
$1,033.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$578.48 |
| Max. Negotiated Rate |
$1,002.01 |
| Rate for Payer: Cash Price |
$619.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$723.10
|
| Rate for Payer: Health Management Network Commercial |
$878.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$929.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,002.01
|
| Rate for Payer: University Health Alliance Commercial |
$578.48
|
|
|
PALINDROME CATH
|
Facility
|
OP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$735.00 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: AlohaCare Medicaid |
$735.00
|
| Rate for Payer: AlohaCare Medicare |
$1,117.20
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Devoted Health Medicare |
$1,234.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,117.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.50
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Humana Medicare |
$1,117.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,117.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,117.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,117.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,117.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.48
|
|
|
PALINDROME CATH
|
Facility
|
IP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,249.50 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
|
|
PALINDROME CATH 8888145018
|
Facility
|
OP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$876.50 |
| Max. Negotiated Rate |
$1,700.41 |
| Rate for Payer: AlohaCare Medicaid |
$876.50
|
| Rate for Payer: AlohaCare Medicare |
$1,332.28
|
| Rate for Payer: Cash Price |
$1,051.80
|
| Rate for Payer: Devoted Health Medicare |
$1,472.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,332.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,665.35
|
| Rate for Payer: Health Management Network Commercial |
$1,490.05
|
| Rate for Payer: Humana Medicare |
$1,332.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,577.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$894.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,332.28
|
| Rate for Payer: MDX Hawaii PPO |
$1,700.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,332.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,332.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,332.28
|
| Rate for Payer: University Health Alliance Commercial |
$1,277.76
|
|
|
PALINDROME CATH 8888145018
|
Facility
|
IP
|
$1,753.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,490.05 |
| Max. Negotiated Rate |
$1,700.41 |
| Rate for Payer: Cash Price |
$1,051.80
|
| Rate for Payer: Health Management Network Commercial |
$1,490.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,577.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,700.41
|
|
|
PALINDROME DIALY CATH 14.5 L
|
Facility
|
IP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,249.50 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
|
|
PALINDROME DIALY CATH 14.5 L
|
Facility
|
OP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$735.00 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: AlohaCare Medicaid |
$735.00
|
| Rate for Payer: AlohaCare Medicare |
$1,117.20
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Devoted Health Medicare |
$1,234.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,117.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.50
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Humana Medicare |
$1,117.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,117.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,117.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,117.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,117.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.48
|
|
|
PALINDROME SPORT 8888119368P
|
Facility
|
IP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,249.50 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
|
|
PALINDROME SPORT 8888119368P
|
Facility
|
OP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$735.00 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: AlohaCare Medicaid |
$735.00
|
| Rate for Payer: AlohaCare Medicare |
$1,117.20
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Devoted Health Medicare |
$1,234.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,117.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.50
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Humana Medicare |
$1,117.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,117.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,117.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,117.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,117.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.48
|
|
|
PALINDROME SPORT KIT
|
Facility
|
IP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,249.50 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
|
