|
BONE GRAFT FILLER 07.704.003S
|
Facility
|
OP
|
$2,944.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.00 |
| Max. Negotiated Rate |
$2,855.68 |
| Rate for Payer: AlohaCare Medicaid |
$1,472.00
|
| Rate for Payer: AlohaCare Medicare |
$2,237.44
|
| Rate for Payer: Cash Price |
$1,766.40
|
| Rate for Payer: Devoted Health Medicare |
$2,472.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,237.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,060.80
|
| Rate for Payer: Health Management Network Commercial |
$2,502.40
|
| Rate for Payer: Humana Medicare |
$2,237.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,649.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,501.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,237.44
|
| Rate for Payer: MDX Hawaii PPO |
$2,855.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,237.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,237.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,237.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,648.64
|
|
|
BONE HARVESTER 8MM STERILE BH8
|
Facility
|
IP
|
$2,998.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,548.30 |
| Max. Negotiated Rate |
$2,908.06 |
| Rate for Payer: Cash Price |
$1,798.80
|
| Rate for Payer: Health Management Network Commercial |
$2,548.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,698.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,908.06
|
|
|
BONE HARVESTER 8MM STERILE BH8
|
Facility
|
OP
|
$2,998.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,499.00 |
| Max. Negotiated Rate |
$2,908.06 |
| Rate for Payer: AlohaCare Medicaid |
$1,499.00
|
| Rate for Payer: AlohaCare Medicare |
$2,278.48
|
| Rate for Payer: Cash Price |
$1,798.80
|
| Rate for Payer: Devoted Health Medicare |
$2,518.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,278.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,848.10
|
| Rate for Payer: Health Management Network Commercial |
$2,548.30
|
| Rate for Payer: Humana Medicare |
$2,278.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,698.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,528.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,278.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,908.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,278.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,278.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,278.48
|
| Rate for Payer: University Health Alliance Commercial |
$2,185.24
|
|
|
BONE TAP CANNULATED 4.5MM
|
Facility
|
OP
|
$1,022.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$511.00 |
| Max. Negotiated Rate |
$991.34 |
| Rate for Payer: AlohaCare Medicaid |
$511.00
|
| Rate for Payer: AlohaCare Medicare |
$776.72
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Devoted Health Medicare |
$858.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$776.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$970.90
|
| Rate for Payer: Health Management Network Commercial |
$868.70
|
| Rate for Payer: Humana Medicare |
$776.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$919.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$521.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$776.72
|
| Rate for Payer: MDX Hawaii PPO |
$991.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$776.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$776.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$776.72
|
| Rate for Payer: University Health Alliance Commercial |
$744.94
|
|
|
BONE TAP CANNULATED 4.5MM
|
Facility
|
IP
|
$1,022.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$868.70 |
| Max. Negotiated Rate |
$991.34 |
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Health Management Network Commercial |
$868.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$919.80
|
| Rate for Payer: MDX Hawaii PPO |
$991.34
|
|
|
BOOT HEELIFT SUSPENSION
|
Facility
|
OP
|
$221.00
|
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$214.37 |
| Rate for Payer: AlohaCare Medicaid |
$110.50
|
| Rate for Payer: AlohaCare Medicare |
$167.96
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Devoted Health Medicare |
$185.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$167.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$154.70
|
| Rate for Payer: Health Management Network Commercial |
$187.85
|
| Rate for Payer: Humana Medicare |
$167.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$112.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$167.96
|
| Rate for Payer: MDX Hawaii PPO |
$214.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$167.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$167.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$167.96
|
| Rate for Payer: University Health Alliance Commercial |
$123.76
|
|
|
BOOT HEELIFT SUSPENSION
|
Facility
|
IP
|
$221.00
|
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$214.37 |
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$154.70
|
| Rate for Payer: Health Management Network Commercial |
$187.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.90
|
| Rate for Payer: MDX Hawaii PPO |
$214.37
|
| Rate for Payer: University Health Alliance Commercial |
$123.76
|
|
|
BOOT MULTI PODUS MED
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
HCPCS L4398
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$35.81 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: AlohaCare Medicaid |
$82.00
|
| Rate for Payer: AlohaCare Medicare |
$124.64
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Devoted Health Medicare |
$137.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$124.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.80
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Humana Medicare |
$124.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$124.64
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$124.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$124.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$124.64
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
BOOT MULTI PODUS MED
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS L4398
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$91.84 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.80
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
BOOT MULTI PODUS XLG
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
HCPCS L4398
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$91.84 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.80
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
BOOT MULTI PODUS XLG
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
HCPCS L4398
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$35.81 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: AlohaCare Medicaid |
$82.00
|
| Rate for Payer: AlohaCare Medicare |
$124.64
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Devoted Health Medicare |
$137.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$124.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.80
|
| Rate for Payer: Health Management Network Commercial |
$139.40
|
| Rate for Payer: Humana Medicare |
$124.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$124.64
|
| Rate for Payer: MDX Hawaii PPO |
$159.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$124.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$124.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$124.64
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [123070]
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
HCPCS J9041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$162.35 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Health Management Network Commercial |
$162.35
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$223.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$185.27
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION [123070]
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS J9041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$240.56 |
| Rate for Payer: AlohaCare Medicaid |
$124.00
|
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicaid |
$95.50
|
| Rate for Payer: AlohaCare Medicare |
$342.00
|
| Rate for Payer: AlohaCare Medicare |
$145.16
|
| Rate for Payer: AlohaCare Medicare |
$188.48
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$114.60
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Cash Price |
$148.80
|
| Rate for Payer: Devoted Health Medicare |
$378.00
|
| Rate for Payer: Devoted Health Medicare |
$208.32
|
| Rate for Payer: Devoted Health Medicare |
$160.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$342.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$145.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$181.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$235.60
|
| Rate for Payer: Health Management Network Commercial |
$162.35
|
| Rate for Payer: Health Management Network Commercial |
$210.80
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$188.48
|
| Rate for Payer: Humana Medicare |
$145.16
|
| Rate for Payer: Humana Medicare |
$342.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$223.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$126.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$97.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$145.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$185.27
|
| Rate for Payer: MDX Hawaii PPO |
$240.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$188.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$145.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$148.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$270.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$145.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$342.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.48
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
| Rate for Payer: University Health Alliance Commercial |
$180.77
|
| Rate for Payer: University Health Alliance Commercial |
$139.22
|
|
|
BOSS REAMER 6543-4-517
|
Facility
|
OP
|
$2,026.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,013.00 |
| Max. Negotiated Rate |
$1,965.22 |
| Rate for Payer: AlohaCare Medicaid |
$1,013.00
|
| Rate for Payer: AlohaCare Medicare |
$1,539.76
|
| Rate for Payer: Cash Price |
$1,215.60
|
| Rate for Payer: Devoted Health Medicare |
$1,701.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,539.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,924.70
|
| Rate for Payer: Health Management Network Commercial |
$1,722.10
|
| Rate for Payer: Humana Medicare |
$1,539.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,823.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,033.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,539.76
|
| Rate for Payer: MDX Hawaii PPO |
$1,965.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,539.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,539.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,539.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,476.75
|
|
|
BOSS REAMER 6543-4-517
|
Facility
|
IP
|
$2,026.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,722.10 |
| Max. Negotiated Rate |
$1,965.22 |
| Rate for Payer: Cash Price |
$1,215.60
|
| Rate for Payer: Health Management Network Commercial |
$1,722.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,823.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,965.22
|
|
|
BOWL SET X/55ML 04350
|
Facility
|
IP
|
$471.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$400.35 |
| Max. Negotiated Rate |
$456.87 |
| Rate for Payer: Cash Price |
$282.60
|
| Rate for Payer: Health Management Network Commercial |
$400.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$423.90
|
| Rate for Payer: MDX Hawaii PPO |
$456.87
|
|
|
BOWL SET X/55ML 04350
|
Facility
|
OP
|
$471.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.50 |
| Max. Negotiated Rate |
$456.87 |
| Rate for Payer: AlohaCare Medicaid |
$235.50
|
| Rate for Payer: AlohaCare Medicare |
$357.96
|
| Rate for Payer: Cash Price |
$282.60
|
| Rate for Payer: Devoted Health Medicare |
$395.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$357.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$447.45
|
| Rate for Payer: Health Management Network Commercial |
$400.35
|
| Rate for Payer: Humana Medicare |
$357.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$423.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$240.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$357.96
|
| Rate for Payer: MDX Hawaii PPO |
$456.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$357.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$357.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$357.96
|
| Rate for Payer: University Health Alliance Commercial |
$343.31
|
|
|
BPLR LINR 58X28 00-5001-057-28
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$612.50
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$787.50
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: University Health Alliance Commercial |
$490.00
|
|
|
BPLR LINR 58X28 00-5001-057-28
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$437.50 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: AlohaCare Medicaid |
$437.50
|
| Rate for Payer: AlohaCare Medicare |
$665.00
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Devoted Health Medicare |
$735.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$665.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$612.50
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Humana Medicare |
$665.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$787.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$446.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$665.00
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$665.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$665.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$665.00
|
| Rate for Payer: University Health Alliance Commercial |
$490.00
|
|
|
BPLR SHELL 57MM 00-5001-057-00
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: AlohaCare Medicaid |
$525.00
|
| Rate for Payer: AlohaCare Medicare |
$798.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Devoted Health Medicare |
$882.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$798.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Humana Medicare |
$798.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$535.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$798.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$798.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$798.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$798.00
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BPLR SHELL 57MM 00-5001-057-00
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.00 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BRACE BACK L/XL 48-60IN
|
Facility
|
IP
|
$918.00
|
|
|
Service Code
|
HCPCS L0456
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$514.08 |
| Max. Negotiated Rate |
$890.46 |
| Rate for Payer: Cash Price |
$550.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$642.60
|
| Rate for Payer: Health Management Network Commercial |
$780.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$826.20
|
| Rate for Payer: MDX Hawaii PPO |
$890.46
|
| Rate for Payer: University Health Alliance Commercial |
$514.08
|
|
|
BRACE BACK L/XL 48-60IN
|
Facility
|
OP
|
$918.00
|
|
|
Service Code
|
HCPCS L0456
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$459.00 |
| Max. Negotiated Rate |
$890.46 |
| Rate for Payer: AlohaCare Medicaid |
$459.00
|
| Rate for Payer: AlohaCare Medicare |
$697.68
|
| Rate for Payer: Cash Price |
$550.80
|
| Rate for Payer: Cash Price |
$550.80
|
| Rate for Payer: Devoted Health Medicare |
$771.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$697.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$642.60
|
| Rate for Payer: Health Management Network Commercial |
$780.30
|
| Rate for Payer: Humana Medicare |
$697.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$826.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$468.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$697.68
|
| Rate for Payer: MDX Hawaii PPO |
$890.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$697.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$697.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$468.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$697.68
|
| Rate for Payer: University Health Alliance Commercial |
$514.08
|
|
|
BRACE HUMERAL OVER SHOULDER LG
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS L3980
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.50
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
| Rate for Payer: University Health Alliance Commercial |
$137.20
|
|
|
BRACE HUMERAL OVER SHOULDER LG
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS L3980
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: AlohaCare Medicaid |
$122.50
|
| Rate for Payer: AlohaCare Medicare |
$186.20
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Devoted Health Medicare |
$205.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.50
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Humana Medicare |
$186.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.20
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.20
|
| Rate for Payer: University Health Alliance Commercial |
$137.20
|
|
