|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802071030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00574705012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
BISACODYL 5 MG TABLET,DELAYED RELEASE [1079]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904640761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BISACODYL 5 MG TABLET,DELAYED RELEASE [1079]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904640761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION [1090]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00536128636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION [1090]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00536128636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.64
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.64
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET [9284]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904720546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET [9284]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904720546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 29300012613
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687067921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687067911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687067911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687067921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET [18288]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 29300012613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
BIVALIRUDIN 250 MG/5ML IV (WET SOLR VIAL) [430160216]
|
Facility
|
IP
|
$1,638.00
|
|
|
Service Code
|
HCPCS J0583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,392.30 |
| Max. Negotiated Rate |
$1,588.86 |
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Health Management Network Commercial |
$1,392.30
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,588.86
|
|
|
BIVALIRUDIN 250 MG/5ML IV (WET SOLR VIAL) [430160216]
|
Facility
|
OP
|
$1,638.00
|
|
|
Service Code
|
HCPCS J0583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$1,588.86 |
| Rate for Payer: AlohaCare Medicaid |
$819.00
|
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$127.68
|
| Rate for Payer: AlohaCare Medicare |
$1,244.88
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$1,375.92
|
| Rate for Payer: Devoted Health Medicare |
$141.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,244.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,556.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$1,392.30
|
| Rate for Payer: Humana Medicare |
$1,244.88
|
| Rate for Payer: Humana Medicare |
$127.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$835.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,244.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,588.86
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,244.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,244.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$982.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,244.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.68
|
| Rate for Payer: University Health Alliance Commercial |
$1,193.94
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [160216]
|
Facility
|
OP
|
$1,638.00
|
|
|
Service Code
|
HCPCS J0583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$1,588.86 |
| Rate for Payer: AlohaCare Medicaid |
$819.00
|
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$127.68
|
| Rate for Payer: AlohaCare Medicare |
$1,244.88
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Devoted Health Medicare |
$1,375.92
|
| Rate for Payer: Devoted Health Medicare |
$141.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,244.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,556.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$1,392.30
|
| Rate for Payer: Humana Medicare |
$1,244.88
|
| Rate for Payer: Humana Medicare |
$127.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$835.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,244.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.68
|
| Rate for Payer: MDX Hawaii PPO |
$1,588.86
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,244.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,244.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$982.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,244.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.68
|
| Rate for Payer: University Health Alliance Commercial |
$1,193.94
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION [160216]
|
Facility
|
IP
|
$1,638.00
|
|
|
Service Code
|
HCPCS J0583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,392.30 |
| Max. Negotiated Rate |
$1,588.86 |
| Rate for Payer: Cash Price |
$982.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Health Management Network Commercial |
$1,392.30
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,474.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,588.86
|
|
|
BLADE 100MM HELICL 04.038.400S
|
Facility
|
IP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,491.84 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 100MM HELICL 04.038.400S
|
Facility
|
OP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.00 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: AlohaCare Medicaid |
$1,332.00
|
| Rate for Payer: AlohaCare Medicare |
$2,024.64
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Devoted Health Medicare |
$2,237.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,024.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Humana Medicare |
$2,024.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,358.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,024.64
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,024.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,024.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,024.64
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 105MM HELICL 04.038.405S
|
Facility
|
OP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.00 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: AlohaCare Medicaid |
$1,332.00
|
| Rate for Payer: AlohaCare Medicare |
$2,024.64
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Devoted Health Medicare |
$2,237.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,024.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Humana Medicare |
$2,024.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,358.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,024.64
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,024.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,024.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,024.64
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 105MM HELICL 04.038.405S
|
Facility
|
IP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,491.84 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 110MM HELICL 04.038.410S
|
Facility
|
OP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.00 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: AlohaCare Medicaid |
$1,332.00
|
| Rate for Payer: AlohaCare Medicare |
$2,024.64
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Devoted Health Medicare |
$2,237.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,024.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Humana Medicare |
$2,024.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,358.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,024.64
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,024.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,024.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,024.64
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 110MM HELICL 04.038.410S
|
Facility
|
IP
|
$2,664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,491.84 |
| Max. Negotiated Rate |
$2,584.08 |
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,864.80
|
| Rate for Payer: Health Management Network Commercial |
$2,264.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,397.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,584.08
|
| Rate for Payer: University Health Alliance Commercial |
$1,491.84
|
|
|
BLADE 11.0M TI HELICAL 85MM
|
Facility
|
IP
|
$2,182.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,221.92 |
| Max. Negotiated Rate |
$2,116.54 |
| Rate for Payer: Cash Price |
$1,309.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,527.40
|
| Rate for Payer: Health Management Network Commercial |
$1,854.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,963.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,116.54
|
| Rate for Payer: University Health Alliance Commercial |
$1,221.92
|
|
