|
TRAY REVERSED TI6AI4V DWF520
|
Facility
|
IP
|
$5,506.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,083.36 |
| Max. Negotiated Rate |
$5,340.82 |
| Rate for Payer: Cash Price |
$3,303.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,854.20
|
| Rate for Payer: Health Management Network Commercial |
$4,680.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,955.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,340.82
|
| Rate for Payer: University Health Alliance Commercial |
$3,083.36
|
|
|
TRAY TIBIAL RT SZ4 02.07.1204R
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,800.00 |
| Max. Negotiated Rate |
$3,492.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,800.00
|
| Rate for Payer: AlohaCare Medicare |
$2,736.00
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Devoted Health Medicare |
$3,024.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,736.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,520.00
|
| Rate for Payer: Health Management Network Commercial |
$3,060.00
|
| Rate for Payer: Humana Medicare |
$2,736.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,240.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,836.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,736.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,492.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,736.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,736.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,736.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,016.00
|
|
|
TRAY TIBIAL RT SZ4 02.07.1204R
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,016.00 |
| Max. Negotiated Rate |
$3,492.00 |
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,520.00
|
| Rate for Payer: Health Management Network Commercial |
$3,060.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,240.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,492.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,016.00
|
|
|
TRAY TIBIAL SIZE A LF MEDIAL
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,900.00 |
| Max. Negotiated Rate |
$3,686.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,900.00
|
| Rate for Payer: AlohaCare Medicare |
$2,888.00
|
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Devoted Health Medicare |
$3,192.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,888.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,660.00
|
| Rate for Payer: Health Management Network Commercial |
$3,230.00
|
| Rate for Payer: Humana Medicare |
$2,888.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,420.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,938.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,888.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,686.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,888.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,888.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,888.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,128.00
|
|
|
TRAY TIBIAL SIZE A LF MEDIAL
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,128.00 |
| Max. Negotiated Rate |
$3,686.00 |
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,660.00
|
| Rate for Payer: Health Management Network Commercial |
$3,230.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,420.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,686.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,128.00
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687045401
|
|
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
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687045411
|
|
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
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687045401
|
|
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
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904686961
|
|
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
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686961
|
|
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
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687045411
|
|
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
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
|
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
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
|
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
|
|
|
TREK RX 3.5X30
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$323.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
|
|
TREK RX 3.5X30
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: AlohaCare Medicaid |
$190.00
|
| Rate for Payer: AlohaCare Medicare |
$288.80
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Devoted Health Medicare |
$319.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$288.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Humana Medicare |
$288.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$288.80
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$288.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$288.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$288.80
|
| Rate for Payer: University Health Alliance Commercial |
$276.98
|
|
|
TREK RX 4X30
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: AlohaCare Medicaid |
$190.00
|
| Rate for Payer: AlohaCare Medicare |
$288.80
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Devoted Health Medicare |
$319.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$288.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Humana Medicare |
$288.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$288.80
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$288.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$288.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$288.80
|
| Rate for Payer: University Health Alliance Commercial |
$276.98
|
|
|
TREK RX 4X30
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$323.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [188830]
|
Facility
|
IP
|
$7,619.00
|
|
|
Service Code
|
HCPCS J9347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,476.15 |
| Max. Negotiated Rate |
$7,390.43 |
| Rate for Payer: MDX Hawaii PPO |
$7,390.43
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Health Management Network Commercial |
$6,476.15
|
| Rate for Payer: Health Management Network Commercial |
$42,640.25
|
| Rate for Payer: Health Management Network Commercial |
$10,979.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,625.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$45,148.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,857.10
|
| Rate for Payer: MDX Hawaii PPO |
$48,660.05
|
| Rate for Payer: MDX Hawaii PPO |
$12,529.49
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [188830]
|
Facility
|
OP
|
$50,165.00
|
|
|
Service Code
|
HCPCS J9347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$48,660.05 |
| Rate for Payer: AlohaCare Medicaid |
$25,082.50
|
| Rate for Payer: AlohaCare Medicaid |
$3,809.50
|
| Rate for Payer: AlohaCare Medicaid |
$6,458.50
|
| Rate for Payer: AlohaCare Medicare |
$5,790.44
|
| Rate for Payer: AlohaCare Medicare |
$38,125.40
|
| Rate for Payer: AlohaCare Medicare |
$9,816.92
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Devoted Health Medicare |
$6,399.96
|
| Rate for Payer: Devoted Health Medicare |
$10,850.28
|
| Rate for Payer: Devoted Health Medicare |
$42,138.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,790.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,816.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38,125.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,271.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,238.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47,656.75
|
| Rate for Payer: Health Management Network Commercial |
$10,979.45
|
| Rate for Payer: Health Management Network Commercial |
$6,476.15
|
| Rate for Payer: Health Management Network Commercial |
$42,640.25
|
| Rate for Payer: Humana Medicare |
$5,790.44
|
| Rate for Payer: Humana Medicare |
$38,125.40
|
| Rate for Payer: Humana Medicare |
$9,816.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,857.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$45,148.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,625.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25,584.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,587.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,885.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,816.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$38,125.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,790.44
|
| Rate for Payer: MDX Hawaii PPO |
$7,390.43
|
| Rate for Payer: MDX Hawaii PPO |
$12,529.49
|
| Rate for Payer: MDX Hawaii PPO |
$48,660.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,816.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38,125.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,790.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,790.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$38,125.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,816.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,750.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30,099.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,571.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$38,125.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,816.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,790.44
|
| Rate for Payer: University Health Alliance Commercial |
$36,565.27
|
| Rate for Payer: University Health Alliance Commercial |
$5,553.49
|
| Rate for Payer: University Health Alliance Commercial |
$9,415.20
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,338.00 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,338.00
|
| Rate for Payer: AlohaCare Medicare |
$2,033.76
|
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Devoted Health Medicare |
$2,247.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,033.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Humana Medicare |
$2,033.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,364.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,033.76
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,033.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,033.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,033.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
IP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$615.40 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$651.60
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
OP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$362.00 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: AlohaCare Medicaid |
$362.00
|
| Rate for Payer: AlohaCare Medicare |
$550.24
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Devoted Health Medicare |
$608.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$550.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$687.80
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: Humana Medicare |
$550.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$651.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$369.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$550.24
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$550.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$550.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$550.24
|
| Rate for Payer: University Health Alliance Commercial |
$527.72
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
