|
PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION [18304]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: AlohaCare Medicaid |
$14.50
|
| Rate for Payer: AlohaCare Medicare |
$22.04
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Devoted Health Medicare |
$24.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Humana Medicare |
$22.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.04
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.04
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G/15 ML IV (WET SOLR VIAL) [43018303]
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G/15 ML IV (WET SOLR VIAL) [43018303]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$25.84
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$28.56
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$25.84
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.84
|
| Rate for Payer: University Health Alliance Commercial |
$24.78
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080103]
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$521.05 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: Cash Price |
$367.80
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080103]
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: AlohaCare Medicaid |
$306.50
|
| Rate for Payer: AlohaCare Medicare |
$465.88
|
| Rate for Payer: Cash Price |
$367.80
|
| Rate for Payer: Cash Price |
$367.80
|
| Rate for Payer: Devoted Health Medicare |
$514.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$465.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$582.35
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Humana Medicare |
$465.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$312.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$465.88
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$465.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$465.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$367.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$465.88
|
| Rate for Payer: University Health Alliance Commercial |
$446.82
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$83.42 |
| Rate for Payer: AlohaCare Medicaid |
$43.00
|
| Rate for Payer: AlohaCare Medicare |
$65.36
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Devoted Health Medicare |
$72.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$81.70
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Humana Medicare |
$65.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.36
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.36
|
| Rate for Payer: University Health Alliance Commercial |
$62.69
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK [34524]
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.10 |
| Max. Negotiated Rate |
$83.42 |
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$52.44
|
| Rate for Payer: AlohaCare Medicare |
$18.24
|
| Rate for Payer: AlohaCare Medicare |
$41.80
|
| Rate for Payer: AlohaCare Medicare |
$44.84
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$49.56
|
| Rate for Payer: Devoted Health Medicare |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$57.96
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$18.24
|
| Rate for Payer: Humana Medicare |
$44.84
|
| Rate for Payer: Humana Medicare |
$41.80
|
| Rate for Payer: Humana Medicare |
$52.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.80
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.80
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
| Rate for Payer: University Health Alliance Commercial |
$50.29
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
PLAT DHS 135D/6H/110MM 281.160
|
Facility
|
IP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 135D/6H/110MM 281.160
|
Facility
|
OP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.00 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,215.00
|
| Rate for Payer: AlohaCare Medicare |
$1,846.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Devoted Health Medicare |
$2,041.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,846.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Humana Medicare |
$1,846.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,239.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,846.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,846.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,846.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,846.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 140D 6H 110MM 281.260
|
Facility
|
OP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.00 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,215.00
|
| Rate for Payer: AlohaCare Medicare |
$1,846.80
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Devoted Health Medicare |
$2,041.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,846.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Humana Medicare |
$1,846.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,239.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,846.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,846.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,846.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,846.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 140D 6H 110MM 281.260
|
Facility
|
IP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 145D/6H/110MM 281.360
|
Facility
|
OP
|
$2,001.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.50 |
| Max. Negotiated Rate |
$1,940.97 |
| Rate for Payer: AlohaCare Medicaid |
$1,000.50
|
| Rate for Payer: AlohaCare Medicare |
$1,520.76
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Devoted Health Medicare |
$1,680.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,520.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.70
|
| Rate for Payer: Health Management Network Commercial |
$1,700.85
|
| Rate for Payer: Humana Medicare |
$1,520.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,520.76
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,520.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,520.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,520.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.56
|
|
|
PLAT DHS 145D/6H/110MM 281.360
|
Facility
|
IP
|
$2,001.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.56 |
| Max. Negotiated Rate |
$1,940.97 |
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.70
|
| Rate for Payer: Health Management Network Commercial |
$1,700.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.97
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.56
|
|
|
PLATE 10 HOLE 629550S
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,153.60 |
| Max. Negotiated Rate |
$1,998.20 |
| Rate for Payer: Cash Price |
$1,236.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,442.00
|
| Rate for Payer: Health Management Network Commercial |
$1,751.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,854.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,998.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,153.60
|
|
|
PLATE 10 HOLE 629550S
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,030.00 |
| Max. Negotiated Rate |
$1,998.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,030.00
|
| Rate for Payer: AlohaCare Medicare |
$1,565.60
|
| Rate for Payer: Cash Price |
$1,236.00
|
| Rate for Payer: Devoted Health Medicare |
$1,730.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,565.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,442.00
|
| Rate for Payer: Health Management Network Commercial |
$1,751.00
|
| Rate for Payer: Humana Medicare |
$1,565.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,854.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,050.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,565.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,998.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,565.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,565.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,565.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,153.60
|
|
|
PLATE 126MM 10H
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,112.50 |
| Max. Negotiated Rate |
$2,158.25 |
| Rate for Payer: AlohaCare Medicaid |
$1,112.50
|
| Rate for Payer: AlohaCare Medicare |
$1,691.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Devoted Health Medicare |
$1,869.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,691.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,557.50
|
| Rate for Payer: Health Management Network Commercial |
$1,891.25
|
| Rate for Payer: Humana Medicare |
$1,691.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,002.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,134.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,691.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,158.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,691.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,691.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,691.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,246.00
|
|
|
PLATE 126MM 10H
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,246.00 |
| Max. Negotiated Rate |
$2,158.25 |
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,557.50
|
| Rate for Payer: Health Management Network Commercial |
$1,891.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,002.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,158.25
|
| Rate for Payer: University Health Alliance Commercial |
$1,246.00
|
|
|
PLATE 1/3 10-HOLE/121MM 241.40
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$235.60
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Devoted Health Medicare |
$260.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$235.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$235.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$235.60
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$235.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$235.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$235.60
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
PLATE 1/3 10-HOLE/121MM 241.40
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
PLATE 1/3 2-HOLE/25MM 241.32
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$213.36 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.70
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: University Health Alliance Commercial |
$213.36
|
|
|
PLATE 1/3 2-HOLE/25MM 241.32
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$190.50 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: AlohaCare Medicaid |
$190.50
|
| Rate for Payer: AlohaCare Medicare |
$289.56
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Devoted Health Medicare |
$320.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.70
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Humana Medicare |
$289.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.56
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.56
|
| Rate for Payer: University Health Alliance Commercial |
$213.36
|
|
