|
STENT CONTOUR VL URETERAL
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$232.40 |
| Max. Negotiated Rate |
$402.55 |
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$290.50
|
| Rate for Payer: Health Management Network Commercial |
$352.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$373.50
|
| Rate for Payer: MDX Hawaii PPO |
$402.55
|
| Rate for Payer: University Health Alliance Commercial |
$232.40
|
|
|
STENT COTTON HUIB 10X12
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT COTTON HUIB 10X12
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: AlohaCare Medicaid |
$142.00
|
| Rate for Payer: AlohaCare Medicare |
$215.84
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Devoted Health Medicare |
$238.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Humana Medicare |
$215.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$215.84
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.84
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT COTTON HUIB 10X15
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT COTTON HUIB 10X15
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: AlohaCare Medicaid |
$142.00
|
| Rate for Payer: AlohaCare Medicare |
$215.84
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Devoted Health Medicare |
$238.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Humana Medicare |
$215.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$215.84
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.84
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT COTTON HUIB 10X5
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$174.72 |
| Max. Negotiated Rate |
$302.64 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$265.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$280.80
|
| Rate for Payer: MDX Hawaii PPO |
$302.64
|
| Rate for Payer: University Health Alliance Commercial |
$174.72
|
|
|
STENT COTTON HUIB 10X5
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$302.64 |
| Rate for Payer: AlohaCare Medicaid |
$156.00
|
| Rate for Payer: AlohaCare Medicare |
$237.12
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Devoted Health Medicare |
$262.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$265.20
|
| Rate for Payer: Humana Medicare |
$237.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$280.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$159.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.12
|
| Rate for Payer: MDX Hawaii PPO |
$302.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$237.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$237.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.12
|
| Rate for Payer: University Health Alliance Commercial |
$174.72
|
|
|
STENT COTTON HUIB 10X7
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$174.72 |
| Max. Negotiated Rate |
$302.64 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$265.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$280.80
|
| Rate for Payer: MDX Hawaii PPO |
$302.64
|
| Rate for Payer: University Health Alliance Commercial |
$174.72
|
|
|
STENT COTTON HUIB 10X7
|
Facility
|
OP
|
$312.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$302.64 |
| Rate for Payer: AlohaCare Medicaid |
$156.00
|
| Rate for Payer: AlohaCare Medicare |
$237.12
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Devoted Health Medicare |
$262.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$265.20
|
| Rate for Payer: Humana Medicare |
$237.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$280.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$159.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.12
|
| Rate for Payer: MDX Hawaii PPO |
$302.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$237.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$237.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.12
|
| Rate for Payer: University Health Alliance Commercial |
$174.72
|
|
|
STENT COTTON HUIB 10X9
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: AlohaCare Medicaid |
$142.00
|
| Rate for Payer: AlohaCare Medicare |
$215.84
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Devoted Health Medicare |
$238.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Humana Medicare |
$215.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$215.84
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.84
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT COTTON HUIB 10X9
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$159.04 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: University Health Alliance Commercial |
$159.04
|
|
|
STENT ENDOPYELOTOMY
|
Facility
|
IP
|
$738.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$413.28 |
| Max. Negotiated Rate |
$715.86 |
| Rate for Payer: Cash Price |
$442.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$516.60
|
| Rate for Payer: Health Management Network Commercial |
$627.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$664.20
|
| Rate for Payer: MDX Hawaii PPO |
$715.86
|
| Rate for Payer: University Health Alliance Commercial |
$413.28
|
|
|
STENT ENDOPYELOTOMY
|
Facility
|
OP
|
$738.00
|
|
|
Service Code
|
HCPCS C2617
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$369.00 |
| Max. Negotiated Rate |
$715.86 |
| Rate for Payer: AlohaCare Medicaid |
$369.00
|
| Rate for Payer: AlohaCare Medicare |
$560.88
|
| Rate for Payer: Cash Price |
$442.80
|
| Rate for Payer: Devoted Health Medicare |
$619.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$560.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$516.60
|
| Rate for Payer: Health Management Network Commercial |
$627.30
|
| Rate for Payer: Humana Medicare |
$560.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$664.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$376.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$560.88
|
| Rate for Payer: MDX Hawaii PPO |
$715.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$560.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$560.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$560.88
|
| Rate for Payer: University Health Alliance Commercial |
$413.28
|
|
|
STENT ERCP BILIARY 11.5X7
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C2625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$856.80 |
| Max. Negotiated Rate |
$1,484.10 |
| Rate for Payer: Cash Price |
$918.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,071.00
|
| Rate for Payer: Health Management Network Commercial |
$1,300.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,377.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,484.10
|
| Rate for Payer: University Health Alliance Commercial |
$856.80
|
|
|
STENT ERCP BILIARY 11.5X7
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C2625
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$1,484.10 |
| Rate for Payer: AlohaCare Medicaid |
$765.00
|
| Rate for Payer: AlohaCare Medicare |
$1,162.80
|
| Rate for Payer: Cash Price |
$918.00
|
| Rate for Payer: Devoted Health Medicare |
$1,285.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,162.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,071.00
|
| Rate for Payer: Health Management Network Commercial |
$1,300.50
|
| Rate for Payer: Humana Medicare |
$1,162.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,377.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$780.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,162.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,484.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,162.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,162.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,162.80
|
| Rate for Payer: University Health Alliance Commercial |
$856.80
|
|
|
STENT ESOPHAGEAL 18MM
|
Facility
|
IP
|
$4,840.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,710.40 |
| Max. Negotiated Rate |
$4,694.80 |
| Rate for Payer: Cash Price |
$2,904.00
|
| Rate for Payer: Cash Price |
$2,904.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Health Management Network Commercial |
$4,114.00
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,694.80
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.40
|
|
|
STENT ESOPHAGEAL 18MM
|
Facility
|
OP
|
$4,840.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,420.00 |
| Max. Negotiated Rate |
$4,694.80 |
| Rate for Payer: AlohaCare Medicaid |
$2,420.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,420.50
|
| Rate for Payer: AlohaCare Medicare |
$3,678.40
|
| Rate for Payer: AlohaCare Medicare |
$3,679.16
|
| Rate for Payer: Cash Price |
$2,904.00
|
| Rate for Payer: Cash Price |
$2,904.60
|
| Rate for Payer: Devoted Health Medicare |
$4,065.60
|
| Rate for Payer: Devoted Health Medicare |
$4,066.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,679.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,678.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.00
|
| Rate for Payer: Health Management Network Commercial |
$4,114.00
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: Humana Medicare |
$3,678.40
|
| Rate for Payer: Humana Medicare |
$3,679.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,468.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,468.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,678.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,679.16
|
| Rate for Payer: MDX Hawaii PPO |
$4,694.80
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,678.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,679.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,679.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,678.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,678.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,679.16
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.40
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
|
|
STENT ESOPHAGEAL 18MMX153
|
Facility
|
IP
|
$4,841.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,710.96 |
| Max. Negotiated Rate |
$4,695.77 |
| Rate for Payer: Cash Price |
$2,904.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.90
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
|
|
STENT ESOPHAGEAL 18MMX153
|
Facility
|
OP
|
$4,841.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,420.50 |
| Max. Negotiated Rate |
$4,695.77 |
| Rate for Payer: AlohaCare Medicaid |
$2,420.50
|
| Rate for Payer: AlohaCare Medicare |
$3,679.16
|
| Rate for Payer: Cash Price |
$2,904.60
|
| Rate for Payer: Devoted Health Medicare |
$4,066.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,679.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: Humana Medicare |
$3,679.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,356.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,468.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,679.16
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,679.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,679.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,679.16
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
|
|
STENT ESOPHAGEAL 23MM
|
Facility
|
OP
|
$5,160.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,580.00 |
| Max. Negotiated Rate |
$5,005.20 |
| Rate for Payer: AlohaCare Medicaid |
$2,580.00
|
| Rate for Payer: AlohaCare Medicare |
$3,921.60
|
| Rate for Payer: Cash Price |
$3,096.00
|
| Rate for Payer: Devoted Health Medicare |
$4,334.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,921.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,612.00
|
| Rate for Payer: Health Management Network Commercial |
$4,386.00
|
| Rate for Payer: Humana Medicare |
$3,921.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,644.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,631.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,921.60
|
| Rate for Payer: MDX Hawaii PPO |
$5,005.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,921.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,921.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,921.60
|
| Rate for Payer: University Health Alliance Commercial |
$2,889.60
|
|
|
STENT ESOPHAGEAL 23MM
|
Facility
|
IP
|
$5,160.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,889.60 |
| Max. Negotiated Rate |
$5,005.20 |
| Rate for Payer: Cash Price |
$3,096.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,612.00
|
| Rate for Payer: Health Management Network Commercial |
$4,386.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,644.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,005.20
|
| Rate for Payer: University Health Alliance Commercial |
$2,889.60
|
|
|
STENT GASTROINTESTINAL DUODENL
|
Facility
|
OP
|
$5,075.00
|
|
|
Service Code
|
HCPCS C1876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,537.50 |
| Max. Negotiated Rate |
$4,922.75 |
| Rate for Payer: AlohaCare Medicaid |
$2,537.50
|
| Rate for Payer: AlohaCare Medicare |
$3,857.00
|
| Rate for Payer: Cash Price |
$3,045.00
|
| Rate for Payer: Devoted Health Medicare |
$4,263.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,857.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,552.50
|
| Rate for Payer: Health Management Network Commercial |
$4,313.75
|
| Rate for Payer: Humana Medicare |
$3,857.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,567.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,588.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,857.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,922.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,857.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,857.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,857.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,842.00
|
|
|
STENT GASTROINTESTINAL DUODENL
|
Facility
|
IP
|
$5,075.00
|
|
|
Service Code
|
HCPCS C1876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,842.00 |
| Max. Negotiated Rate |
$4,922.75 |
| Rate for Payer: Cash Price |
$3,045.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,552.50
|
| Rate for Payer: Health Management Network Commercial |
$4,313.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,567.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,922.75
|
| Rate for Payer: University Health Alliance Commercial |
$2,842.00
|
|
|
STENT GRAFT AAA26X20 TGM262610
|
Facility
|
IP
|
$44,598.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24,974.88 |
| Max. Negotiated Rate |
$43,260.06 |
| Rate for Payer: Cash Price |
$26,758.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31,218.60
|
| Rate for Payer: Health Management Network Commercial |
$37,908.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$40,138.20
|
| Rate for Payer: MDX Hawaii PPO |
$43,260.06
|
| Rate for Payer: University Health Alliance Commercial |
$24,974.88
|
|
|
STENT GRAFT AAA26X20 TGM262610
|
Facility
|
OP
|
$44,598.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,299.00 |
| Max. Negotiated Rate |
$43,260.06 |
| Rate for Payer: AlohaCare Medicaid |
$22,299.00
|
| Rate for Payer: AlohaCare Medicare |
$33,894.48
|
| Rate for Payer: Cash Price |
$26,758.80
|
| Rate for Payer: Devoted Health Medicare |
$37,462.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33,894.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31,218.60
|
| Rate for Payer: Health Management Network Commercial |
$37,908.30
|
| Rate for Payer: Humana Medicare |
$33,894.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$40,138.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22,744.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$33,894.48
|
| Rate for Payer: MDX Hawaii PPO |
$43,260.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33,894.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$33,894.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$33,894.48
|
| Rate for Payer: University Health Alliance Commercial |
$24,974.88
|
|
