|
TISSEEL DUPLOSPRAY 060-1130
|
Facility
|
IP
|
$436.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$370.60 |
| Max. Negotiated Rate |
$422.92 |
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Health Management Network Commercial |
$370.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$392.40
|
| Rate for Payer: MDX Hawaii PPO |
$422.92
|
|
|
TISSEEL DUPLOSPRAY 060-1130
|
Facility
|
OP
|
$436.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$218.00 |
| Max. Negotiated Rate |
$422.92 |
| Rate for Payer: AlohaCare Medicaid |
$218.00
|
| Rate for Payer: AlohaCare Medicare |
$331.36
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Devoted Health Medicare |
$366.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$331.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$414.20
|
| Rate for Payer: Health Management Network Commercial |
$370.60
|
| Rate for Payer: Humana Medicare |
$331.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$392.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$222.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$331.36
|
| Rate for Payer: MDX Hawaii PPO |
$422.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$331.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$331.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$331.36
|
| Rate for Payer: University Health Alliance Commercial |
$317.80
|
|
|
TISSEEL FROZEN 10ML KT 1506080
|
Facility
|
OP
|
$2,115.00
|
|
|
Service Code
|
HCPCS C9250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.62 |
| Max. Negotiated Rate |
$2,051.55 |
| Rate for Payer: AlohaCare Medicaid |
$1,057.50
|
| Rate for Payer: AlohaCare Medicare |
$1,607.40
|
| Rate for Payer: Cash Price |
$1,269.00
|
| Rate for Payer: Cash Price |
$1,269.00
|
| Rate for Payer: Devoted Health Medicare |
$1,776.60
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,607.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,009.25
|
| Rate for Payer: Health Management Network Commercial |
$1,797.75
|
| Rate for Payer: Humana Medicare |
$1,607.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,903.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,078.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,607.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,051.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,607.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,607.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,269.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,607.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,541.62
|
|
|
TISSEEL FROZEN 10ML KT 1506080
|
Facility
|
IP
|
$2,115.00
|
|
|
Service Code
|
HCPCS C9250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,797.75 |
| Max. Negotiated Rate |
$2,051.55 |
| Rate for Payer: Cash Price |
$1,269.00
|
| Rate for Payer: Health Management Network Commercial |
$1,797.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,903.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,051.55
|
|
|
TISSEEL VHSD FROZEN 4ML KIT
|
Facility
|
OP
|
$929.00
|
|
|
Service Code
|
HCPCS C9250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.62 |
| Max. Negotiated Rate |
$901.13 |
| Rate for Payer: AlohaCare Medicaid |
$464.50
|
| Rate for Payer: AlohaCare Medicare |
$706.04
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Devoted Health Medicare |
$780.36
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$706.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$882.55
|
| Rate for Payer: Health Management Network Commercial |
$789.65
|
| Rate for Payer: Humana Medicare |
$706.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$836.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$473.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$706.04
|
| Rate for Payer: MDX Hawaii PPO |
$901.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$706.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$706.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$557.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$706.04
|
| Rate for Payer: University Health Alliance Commercial |
$677.15
|
|
|
TISSEEL VHSD FROZEN 4ML KIT
|
Facility
|
IP
|
$929.00
|
|
|
Service Code
|
HCPCS C9250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$789.65 |
| Max. Negotiated Rate |
$901.13 |
| Rate for Payer: Cash Price |
$557.40
|
| Rate for Payer: Health Management Network Commercial |
$789.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$836.10
|
| Rate for Payer: MDX Hawaii PPO |
$901.13
|
|
|
TISSUE MICROMATRIX MM1000
|
Facility
|
IP
|
$5,436.00
|
|
|
Service Code
|
HCPCS Q4118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,620.60 |
| Max. Negotiated Rate |
$5,272.92 |
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Health Management Network Commercial |
$4,620.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,892.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,272.92
|
|
|
TISSUE MICROMATRIX MM1000
|
Facility
|
OP
|
$5,436.00
|
|
|
Service Code
|
HCPCS Q4118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$5,272.92 |
| Rate for Payer: AlohaCare Medicaid |
$2,718.00
|
| Rate for Payer: AlohaCare Medicare |
$4,131.36
|
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Devoted Health Medicare |
$4,566.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,131.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,164.20
|
| Rate for Payer: Health Management Network Commercial |
$4,620.60
|
| Rate for Payer: Humana Medicare |
$4,131.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,892.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,772.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,131.36
|
| Rate for Payer: MDX Hawaii PPO |
$5,272.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,131.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,131.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,261.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,131.36
|
| Rate for Payer: University Health Alliance Commercial |
$3,962.30
|
|
|
TISSUE RETRIEVAL TRS-ROBO-8
|
Facility
|
OP
|
$450.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$342.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Devoted Health Medicare |
$378.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$342.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$342.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$342.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$342.00
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
|
|
TISSUE RETRIEVAL TRS-ROBO-8
|
Facility
|
IP
|
$450.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
|
|
TISSUE TRACE ALLOGRAFT 400145
|
Facility
|
OP
|
$996.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.00 |
| Max. Negotiated Rate |
$966.12 |
| Rate for Payer: AlohaCare Medicaid |
$498.00
|
| Rate for Payer: AlohaCare Medicare |
$756.96
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Devoted Health Medicare |
$836.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$756.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$697.20
|
| Rate for Payer: Health Management Network Commercial |
$846.60
|
| Rate for Payer: Humana Medicare |
$756.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$896.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$507.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$756.96
|
| Rate for Payer: MDX Hawaii PPO |
$966.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$756.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$756.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$756.96
|
| Rate for Payer: University Health Alliance Commercial |
$557.76
|
|
|
TISSUE TRACE ALLOGRAFT 400145
|
Facility
|
IP
|
$996.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$557.76 |
| Max. Negotiated Rate |
$966.12 |
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$697.20
|
| Rate for Payer: Health Management Network Commercial |
$846.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$896.40
|
| Rate for Payer: MDX Hawaii PPO |
$966.12
|
| Rate for Payer: University Health Alliance Commercial |
$557.76
|
|
|
TITAN END CAP T25 STARDR 0MM
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$509.60 |
| Max. Negotiated Rate |
$882.70 |
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$637.00
|
| Rate for Payer: Health Management Network Commercial |
$773.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$819.00
|
| Rate for Payer: MDX Hawaii PPO |
$882.70
|
| Rate for Payer: University Health Alliance Commercial |
$509.60
|
|
|
TITAN END CAP T25 STARDR 0MM
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$882.70 |
| Rate for Payer: AlohaCare Medicaid |
$455.00
|
| Rate for Payer: AlohaCare Medicare |
$691.60
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Devoted Health Medicare |
$764.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$691.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$637.00
|
| Rate for Payer: Health Management Network Commercial |
$773.50
|
| Rate for Payer: Humana Medicare |
$691.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$819.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$464.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$691.60
|
| Rate for Payer: MDX Hawaii PPO |
$882.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$691.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$691.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$691.60
|
| Rate for Payer: University Health Alliance Commercial |
$509.60
|
|
|
TIXAGEV AND CILGAV
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS Q0220
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084064511
|
|
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
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084064501
|
|
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
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084064511
|
|
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
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084064565
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084064565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084064501
|
|
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
|
|
|
TL 1-HOLE POST 54-11600
|
Facility
|
OP
|
$489.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.50 |
| Max. Negotiated Rate |
$474.33 |
| Rate for Payer: AlohaCare Medicaid |
$244.50
|
| Rate for Payer: AlohaCare Medicare |
$371.64
|
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Devoted Health Medicare |
$410.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$371.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.55
|
| Rate for Payer: Health Management Network Commercial |
$415.65
|
| Rate for Payer: Humana Medicare |
$371.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$440.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$249.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$371.64
|
| Rate for Payer: MDX Hawaii PPO |
$474.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$371.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$371.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$371.64
|
| Rate for Payer: University Health Alliance Commercial |
$356.43
|
|
|
TL 1-HOLE POST 54-11600
|
Facility
|
IP
|
$489.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$415.65 |
| Max. Negotiated Rate |
$474.33 |
| Rate for Payer: Cash Price |
$293.40
|
| Rate for Payer: Health Management Network Commercial |
$415.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$440.10
|
| Rate for Payer: MDX Hawaii PPO |
$474.33
|
|
|
TNSN BND NR2X2H/MAL 04.503.701
|
Facility
|
OP
|
$1,962.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$981.00 |
| Max. Negotiated Rate |
$1,903.14 |
| Rate for Payer: Ohana Health Plan Medicare |
$1,491.12
|
| Rate for Payer: AlohaCare Medicaid |
$981.00
|
| Rate for Payer: AlohaCare Medicare |
$1,491.12
|
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Devoted Health Medicare |
$1,648.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,491.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,373.40
|
| Rate for Payer: Health Management Network Commercial |
$1,667.70
|
| Rate for Payer: Humana Medicare |
$1,491.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,765.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,000.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,491.12
|
| Rate for Payer: MDX Hawaii PPO |
$1,903.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,491.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,491.12
|
| Rate for Payer: University Health Alliance Commercial |
$1,098.72
|
|
|
TNSN BND NR2X2H/MAL 04.503.701
|
Facility
|
IP
|
$1,962.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,098.72 |
| Max. Negotiated Rate |
$1,903.14 |
| Rate for Payer: Cash Price |
$1,177.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,373.40
|
| Rate for Payer: Health Management Network Commercial |
$1,667.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,765.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,903.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,098.72
|
|
