|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65162021210
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65162021210
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65862069201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65862069201
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51672411101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 58151011801
|
|
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
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00071374066
|
|
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
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 58151011801
|
|
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
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00071374066
|
|
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
|
|
|
PHOSPHORIC ACID 37% 1126979
|
Facility
|
IP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
|
PHOSPHORIC ACID 37% 1126979
|
Facility
|
OP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$100.32
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.32
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.32
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [8718]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [8718]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: AlohaCare Medicaid |
$59.00
|
| Rate for Payer: AlohaCare Medicare |
$89.68
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Devoted Health Medicare |
$99.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Humana Medicare |
$89.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.68
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.68
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [41624]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [41624]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
PHYTONADIONE (VITAMIN K) 1 MG/ML ORAL SOLUTION [4080281]
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: AlohaCare Medicaid |
$37.00
|
| Rate for Payer: AlohaCare Medicare |
$56.24
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$62.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.30
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Humana Medicare |
$56.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.24
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.24
|
| Rate for Payer: University Health Alliance Commercial |
$53.94
|
|
|
PHYTONADIONE (VITAMIN K) 1 MG/ML ORAL SOLUTION [4080281]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
PICO TWO DRSG 10X20 66022002
|
Facility
|
IP
|
$788.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$669.80 |
| Max. Negotiated Rate |
$764.36 |
| Rate for Payer: Cash Price |
$472.80
|
| Rate for Payer: Health Management Network Commercial |
$669.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$709.20
|
| Rate for Payer: MDX Hawaii PPO |
$764.36
|
|
|
PICO TWO DRSG 10X20 66022002
|
Facility
|
OP
|
$788.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$394.00 |
| Max. Negotiated Rate |
$764.36 |
| Rate for Payer: AlohaCare Medicaid |
$394.00
|
| Rate for Payer: AlohaCare Medicare |
$598.88
|
| Rate for Payer: Cash Price |
$472.80
|
| Rate for Payer: Devoted Health Medicare |
$661.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$598.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$748.60
|
| Rate for Payer: Health Management Network Commercial |
$669.80
|
| Rate for Payer: Humana Medicare |
$598.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$709.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$401.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$598.88
|
| Rate for Payer: MDX Hawaii PPO |
$764.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$598.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$598.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$598.88
|
| Rate for Payer: University Health Alliance Commercial |
$574.37
|
|
|
PICO TWO DRSG 10X30 66022003
|
Facility
|
OP
|
$788.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$394.00 |
| Max. Negotiated Rate |
$764.36 |
| Rate for Payer: AlohaCare Medicaid |
$394.00
|
| Rate for Payer: AlohaCare Medicare |
$598.88
|
| Rate for Payer: Cash Price |
$472.80
|
| Rate for Payer: Devoted Health Medicare |
$661.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$598.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$748.60
|
| Rate for Payer: Health Management Network Commercial |
$669.80
|
| Rate for Payer: Humana Medicare |
$598.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$709.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$401.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$598.88
|
| Rate for Payer: MDX Hawaii PPO |
$764.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$598.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$598.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$598.88
|
| Rate for Payer: University Health Alliance Commercial |
$574.37
|
|
|
PICO TWO DRSG 10X30 66022003
|
Facility
|
IP
|
$788.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$669.80 |
| Max. Negotiated Rate |
$764.36 |
| Rate for Payer: Cash Price |
$472.80
|
| Rate for Payer: Health Management Network Commercial |
$669.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$709.20
|
| Rate for Payer: MDX Hawaii PPO |
$764.36
|
|
|
PICO TWO DRSG 10X40 66022004
|
Facility
|
IP
|
$1,470.00
|
|
|
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
|
|
|
PICO TWO DRSG 10X40 66022004
|
Facility
|
OP
|
$1,470.00
|
|
|
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
|
|
|
PILLOW HIP ABDUCT LRG
|
Facility
|
IP
|
$143.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$121.55 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.70
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
|
|
PILLOW HIP ABDUCT LRG
|
Facility
|
OP
|
$143.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$138.71 |
| Rate for Payer: AlohaCare Medicaid |
$71.50
|
| Rate for Payer: AlohaCare Medicare |
$108.68
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Devoted Health Medicare |
$120.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.85
|
| Rate for Payer: Health Management Network Commercial |
$121.55
|
| Rate for Payer: Humana Medicare |
$108.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.68
|
| Rate for Payer: MDX Hawaii PPO |
$138.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.68
|
| Rate for Payer: University Health Alliance Commercial |
$104.23
|
|
