|
TI END CAP T40X15MM 04.003.003
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$395.50 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$601.16
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$664.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$601.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$553.70
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$601.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$403.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$601.16
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$601.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$601.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$601.16
|
| Rate for Payer: University Health Alliance Commercial |
$442.96
|
|
|
TI END CAP T40X20MM 04.003.004
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$395.50 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$601.16
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$664.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$601.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$553.70
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$601.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$403.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$601.16
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$601.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$601.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$601.16
|
| Rate for Payer: University Health Alliance Commercial |
$442.96
|
|
|
TI END CAP T40X20MM 04.003.004
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.96 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$553.70
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: University Health Alliance Commercial |
$442.96
|
|
|
TI END CAP T40X5MM 04.003.001
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$395.50 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$601.16
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$664.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$601.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$553.70
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$601.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$403.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$601.16
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$601.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$601.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$601.16
|
| Rate for Payer: University Health Alliance Commercial |
$442.96
|
|
|
TI END CAP T40X5MM 04.003.001
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.96 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$553.70
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: University Health Alliance Commercial |
$442.96
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS J3243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$227.95 |
| Rate for Payer: AlohaCare Medicaid |
$117.50
|
| Rate for Payer: AlohaCare Medicaid |
$140.50
|
| Rate for Payer: AlohaCare Medicaid |
$94.50
|
| Rate for Payer: AlohaCare Medicare |
$213.56
|
| Rate for Payer: AlohaCare Medicare |
$143.64
|
| Rate for Payer: AlohaCare Medicare |
$178.60
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Devoted Health Medicare |
$236.04
|
| Rate for Payer: Devoted Health Medicare |
$197.40
|
| Rate for Payer: Devoted Health Medicare |
$158.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$178.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$213.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$143.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$179.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$223.25
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: Health Management Network Commercial |
$199.75
|
| Rate for Payer: Health Management Network Commercial |
$238.85
|
| Rate for Payer: Humana Medicare |
$178.60
|
| Rate for Payer: Humana Medicare |
$143.64
|
| Rate for Payer: Humana Medicare |
$213.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$211.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$252.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$170.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$119.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$143.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$178.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$143.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$213.56
|
| Rate for Payer: MDX Hawaii PPO |
$272.57
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
| Rate for Payer: MDX Hawaii PPO |
$227.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$178.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$213.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$143.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$213.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$143.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$178.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$113.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$141.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$168.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$143.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$213.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$178.60
|
| Rate for Payer: University Health Alliance Commercial |
$204.82
|
| Rate for Payer: University Health Alliance Commercial |
$171.29
|
| Rate for Payer: University Health Alliance Commercial |
$137.76
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS J3243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$199.75 |
| Max. Negotiated Rate |
$227.95 |
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Health Management Network Commercial |
$238.85
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: Health Management Network Commercial |
$199.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$252.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$211.50
|
| Rate for Payer: MDX Hawaii PPO |
$227.95
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
| Rate for Payer: MDX Hawaii PPO |
$272.57
|
|
|
TIGHTROPE ABS 14MM AR-1588TB-1
|
Facility
|
IP
|
$1,071.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.76 |
| Max. Negotiated Rate |
$1,038.87 |
| Rate for Payer: Cash Price |
$642.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$749.70
|
| Rate for Payer: Health Management Network Commercial |
$910.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$963.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,038.87
|
| Rate for Payer: University Health Alliance Commercial |
$599.76
|
|
|
TIGHTROPE ABS 14MM AR-1588TB-1
|
Facility
|
OP
|
$1,071.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$1,038.87 |
| Rate for Payer: AlohaCare Medicaid |
$535.50
|
| Rate for Payer: AlohaCare Medicare |
$813.96
|
| Rate for Payer: Cash Price |
$642.60
|
| Rate for Payer: Devoted Health Medicare |
$899.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$813.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$749.70
|
| Rate for Payer: Health Management Network Commercial |
$910.35
|
| Rate for Payer: Humana Medicare |
$813.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$963.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$546.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$813.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,038.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$813.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$813.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$813.96
|
| Rate for Payer: University Health Alliance Commercial |
$599.76
|
|
|
TIGHTROPE ABS 8X12 AR-1588TB
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.64 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: Cash Price |
$461.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$538.30
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
| Rate for Payer: University Health Alliance Commercial |
$430.64
|
|
|
TIGHTROPE ABS 8X12 AR-1588TB
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.50 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: AlohaCare Medicaid |
$384.50
|
| Rate for Payer: AlohaCare Medicare |
$584.44
|
| Rate for Payer: Cash Price |
$461.40
|
| Rate for Payer: Devoted Health Medicare |
$645.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$584.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$538.30
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Humana Medicare |
$584.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$392.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$584.44
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$584.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$584.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$584.44
|
| Rate for Payer: University Health Alliance Commercial |
$430.64
|
|
|
TIGHTROPE ABS AR-1588TB-3IB
|
Facility
|
IP
|
$1,011.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$566.16 |
| Max. Negotiated Rate |
$980.67 |
| Rate for Payer: Cash Price |
$606.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$707.70
|
| Rate for Payer: Health Management Network Commercial |
$859.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$909.90
|
| Rate for Payer: MDX Hawaii PPO |
$980.67
|
| Rate for Payer: University Health Alliance Commercial |
$566.16
|
|
|
TIGHTROPE ABS AR-1588TB-3IB
|
Facility
|
OP
|
$1,011.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.50 |
| Max. Negotiated Rate |
$980.67 |
| Rate for Payer: AlohaCare Medicaid |
$505.50
|
| Rate for Payer: AlohaCare Medicare |
$768.36
|
| Rate for Payer: Cash Price |
$606.60
|
| Rate for Payer: Devoted Health Medicare |
$849.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$768.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$707.70
|
| Rate for Payer: Health Management Network Commercial |
$859.35
|
| Rate for Payer: Humana Medicare |
$768.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$909.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$515.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$768.36
|
| Rate for Payer: MDX Hawaii PPO |
$980.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$768.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$768.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$768.36
|
| Rate for Payer: University Health Alliance Commercial |
$566.16
|
|
|
TIGHTROPE ABS #AR-1588TN
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$386.40 |
| Max. Negotiated Rate |
$669.30 |
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$483.00
|
| Rate for Payer: Health Management Network Commercial |
$586.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$621.00
|
| Rate for Payer: MDX Hawaii PPO |
$669.30
|
| Rate for Payer: University Health Alliance Commercial |
$386.40
|
|
|
TIGHTROPE ABS #AR-1588TN
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$669.30 |
| Rate for Payer: AlohaCare Medicaid |
$345.00
|
| Rate for Payer: AlohaCare Medicare |
$524.40
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Devoted Health Medicare |
$579.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$524.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$483.00
|
| Rate for Payer: Health Management Network Commercial |
$586.50
|
| Rate for Payer: Humana Medicare |
$524.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$621.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$351.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$524.40
|
| Rate for Payer: MDX Hawaii PPO |
$669.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$524.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$524.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$524.40
|
| Rate for Payer: University Health Alliance Commercial |
$386.40
|
|
|
TIGHTROPE ACL AR-1588RTT
|
Facility
|
OP
|
$1,654.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$827.00 |
| Max. Negotiated Rate |
$1,604.38 |
| Rate for Payer: AlohaCare Medicaid |
$827.00
|
| Rate for Payer: AlohaCare Medicare |
$1,257.04
|
| Rate for Payer: Cash Price |
$992.40
|
| Rate for Payer: Devoted Health Medicare |
$1,389.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,257.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,157.80
|
| Rate for Payer: Health Management Network Commercial |
$1,405.90
|
| Rate for Payer: Humana Medicare |
$1,257.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,488.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$843.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,257.04
|
| Rate for Payer: MDX Hawaii PPO |
$1,604.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,257.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,257.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,257.04
|
| Rate for Payer: University Health Alliance Commercial |
$926.24
|
|
|
TIGHTROPE ACL AR-1588RTT
|
Facility
|
IP
|
$1,654.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.24 |
| Max. Negotiated Rate |
$1,604.38 |
| Rate for Payer: Cash Price |
$992.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,157.80
|
| Rate for Payer: Health Management Network Commercial |
$1,405.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,488.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,604.38
|
| Rate for Payer: University Health Alliance Commercial |
$926.24
|
|
|
TIGHTROPE ACL RT #AR-1588RT
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
|
TIGHTROPE ACL RT #AR-1588RT
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: AlohaCare Medicaid |
$750.00
|
| Rate for Payer: AlohaCare Medicare |
$1,140.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Devoted Health Medicare |
$1,260.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,140.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Humana Medicare |
$1,140.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$765.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,140.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,140.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,140.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,140.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
|
TIGHTROPE ACL RT #AR-1588RTS
|
Facility
|
IP
|
$1,929.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,080.24 |
| Max. Negotiated Rate |
$1,871.13 |
| Rate for Payer: Cash Price |
$1,157.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,350.30
|
| Rate for Payer: Health Management Network Commercial |
$1,639.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,736.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,871.13
|
| Rate for Payer: University Health Alliance Commercial |
$1,080.24
|
|
|
TIGHTROPE ACL RT #AR-1588RTS
|
Facility
|
OP
|
$1,929.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$964.50 |
| Max. Negotiated Rate |
$1,871.13 |
| Rate for Payer: AlohaCare Medicaid |
$964.50
|
| Rate for Payer: AlohaCare Medicare |
$1,466.04
|
| Rate for Payer: Cash Price |
$1,157.40
|
| Rate for Payer: Devoted Health Medicare |
$1,620.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,466.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,350.30
|
| Rate for Payer: Health Management Network Commercial |
$1,639.65
|
| Rate for Payer: Humana Medicare |
$1,466.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,736.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$983.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,466.04
|
| Rate for Payer: MDX Hawaii PPO |
$1,871.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,466.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,466.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,466.04
|
| Rate for Payer: University Health Alliance Commercial |
$1,080.24
|
|
|
TIGHTROPE ACL SUT AR-1588RT-J
|
Facility
|
OP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.50 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: AlohaCare Medicaid |
$647.50
|
| Rate for Payer: AlohaCare Medicare |
$984.20
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Devoted Health Medicare |
$1,087.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$984.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Humana Medicare |
$984.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$660.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$984.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$984.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$984.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$984.20
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
TIGHTROPE ACL SUT AR-1588RT-J
|
Facility
|
IP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$725.20 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
TIGHT ROPE BTB AR-1588BTB-IB
|
Facility
|
IP
|
$2,150.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,204.00 |
| Max. Negotiated Rate |
$2,085.50 |
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,505.00
|
| Rate for Payer: Health Management Network Commercial |
$1,827.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,935.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,085.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,204.00
|
|
|
TIGHT ROPE BTB AR-1588BTB-IB
|
Facility
|
OP
|
$2,150.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.00 |
| Max. Negotiated Rate |
$2,085.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,075.00
|
| Rate for Payer: AlohaCare Medicare |
$1,634.00
|
| Rate for Payer: Cash Price |
$1,290.00
|
| Rate for Payer: Devoted Health Medicare |
$1,806.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,634.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,505.00
|
| Rate for Payer: Health Management Network Commercial |
$1,827.50
|
| Rate for Payer: Humana Medicare |
$1,634.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,935.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,096.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,634.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,085.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,634.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,634.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,634.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,204.00
|
|
