|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00168000680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$37.24
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Devoted Health Medicare |
$41.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$37.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.24
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.24
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 45802005535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$15.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$15.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT [8118]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 51672128401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J3301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J3301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$38.76
|
| Rate for Payer: AlohaCare Medicare |
$36.48
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$40.32
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$36.48
|
| Rate for Payer: Humana Medicare |
$38.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.48
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.76
|
| Rate for Payer: University Health Alliance Commercial |
$34.99
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS J3301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$119.32
|
| Rate for Payer: AlohaCare Medicare |
$114.00
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$126.00
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Devoted Health Medicare |
$131.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$119.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$149.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$114.00
|
| Rate for Payer: Humana Medicare |
$119.32
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$90.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
| Rate for Payer: University Health Alliance Commercial |
$114.44
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J3301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$94.20
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 72578009001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 72578009001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
TRI ASYMX3 PATELLA 5551-G-299
|
Facility
|
OP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.50 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,170.50
|
| Rate for Payer: AlohaCare Medicare |
$1,779.16
|
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Devoted Health Medicare |
$1,966.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,779.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Humana Medicare |
$1,779.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,779.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,779.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,779.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,779.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA 5551-G-299
|
Facility
|
IP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.96 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA 5551-G-350
|
Facility
|
OP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.50 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,170.50
|
| Rate for Payer: AlohaCare Medicare |
$1,779.16
|
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Devoted Health Medicare |
$1,966.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,779.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Humana Medicare |
$1,779.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,779.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,779.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,779.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,779.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA 5551-G-350
|
Facility
|
IP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.96 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA #5551-G-381
|
Facility
|
OP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.50 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,170.50
|
| Rate for Payer: AlohaCare Medicare |
$1,779.16
|
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Devoted Health Medicare |
$1,966.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,779.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Humana Medicare |
$1,779.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,779.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,779.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,779.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,779.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA #5551-G-381
|
Facility
|
IP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.96 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA #5551-G-401
|
Facility
|
OP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.50 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,170.50
|
| Rate for Payer: AlohaCare Medicare |
$1,779.16
|
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Devoted Health Medicare |
$1,966.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,779.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Humana Medicare |
$1,779.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,779.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,779.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,779.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,779.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRI ASYMX3 PATELLA #5551-G-401
|
Facility
|
IP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.96 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRIATHLN PE FEMUR #5515-F-502
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,141.00 |
| Max. Negotiated Rate |
$4,153.54 |
| Rate for Payer: AlohaCare Medicaid |
$2,141.00
|
| Rate for Payer: AlohaCare Medicare |
$3,254.32
|
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Devoted Health Medicare |
$3,596.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,254.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,997.40
|
| Rate for Payer: Health Management Network Commercial |
$3,639.70
|
| Rate for Payer: Humana Medicare |
$3,254.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,853.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,183.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,254.32
|
| Rate for Payer: MDX Hawaii PPO |
$4,153.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,254.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,254.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,254.32
|
| Rate for Payer: University Health Alliance Commercial |
$2,397.92
|
|
|
TRIATHLN PE FEMUR #5515-F-502
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,397.92 |
| Max. Negotiated Rate |
$4,153.54 |
| Rate for Payer: Cash Price |
$2,569.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,997.40
|
| Rate for Payer: Health Management Network Commercial |
$3,639.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,853.80
|
| Rate for Payer: MDX Hawaii PPO |
$4,153.54
|
| Rate for Payer: University Health Alliance Commercial |
$2,397.92
|
|
|
TRIATHLN TIBIA PLT 5521-B-500
|
Facility
|
OP
|
$3,311.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.50 |
| Max. Negotiated Rate |
$3,211.67 |
| Rate for Payer: AlohaCare Medicaid |
$1,655.50
|
| Rate for Payer: AlohaCare Medicare |
$2,516.36
|
| Rate for Payer: Cash Price |
$1,986.60
|
| Rate for Payer: Devoted Health Medicare |
$2,781.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,516.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,317.70
|
| Rate for Payer: Health Management Network Commercial |
$2,814.35
|
| Rate for Payer: Humana Medicare |
$2,516.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,979.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,688.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,516.36
|
| Rate for Payer: MDX Hawaii PPO |
$3,211.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,516.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,516.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,516.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,854.16
|
|
|
TRIATHLN TIBIA PLT 5521-B-500
|
Facility
|
IP
|
$3,311.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,854.16 |
| Max. Negotiated Rate |
$3,211.67 |
| Rate for Payer: Cash Price |
$1,986.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,317.70
|
| Rate for Payer: Health Management Network Commercial |
$2,814.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,979.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,211.67
|
| Rate for Payer: University Health Alliance Commercial |
$1,854.16
|
|
|
TRIATHLN TIBIA PLT 5521-B-600
|
Facility
|
OP
|
$3,311.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.50 |
| Max. Negotiated Rate |
$3,211.67 |
| Rate for Payer: AlohaCare Medicaid |
$1,655.50
|
| Rate for Payer: AlohaCare Medicare |
$2,516.36
|
| Rate for Payer: Cash Price |
$1,986.60
|
| Rate for Payer: Devoted Health Medicare |
$2,781.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,516.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,317.70
|
| Rate for Payer: Health Management Network Commercial |
$2,814.35
|
| Rate for Payer: Humana Medicare |
$2,516.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,979.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,688.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,516.36
|
| Rate for Payer: MDX Hawaii PPO |
$3,211.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,516.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,516.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,516.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,854.16
|
|
|
TRIATHLN TIBIA PLT 5521-B-600
|
Facility
|
IP
|
$3,311.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,854.16 |
| Max. Negotiated Rate |
$3,211.67 |
| Rate for Payer: Cash Price |
$1,986.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,317.70
|
| Rate for Payer: Health Management Network Commercial |
$2,814.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,979.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,211.67
|
| Rate for Payer: University Health Alliance Commercial |
$1,854.16
|
|
|
TRIATHLON 10X32MM 5551-G-320-E
|
Facility
|
IP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.96 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
|
TRIATHLON 10X32MM 5551-G-320-E
|
Facility
|
OP
|
$2,341.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.50 |
| Max. Negotiated Rate |
$2,270.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,170.50
|
| Rate for Payer: AlohaCare Medicare |
$1,779.16
|
| Rate for Payer: Cash Price |
$1,404.60
|
| Rate for Payer: Devoted Health Medicare |
$1,966.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,779.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,638.70
|
| Rate for Payer: Health Management Network Commercial |
$1,989.85
|
| Rate for Payer: Humana Medicare |
$1,779.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,106.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,193.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,779.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,270.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,779.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,779.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,779.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,310.96
|
|
