|
CARVEDILOL 6.25 MG TABLET [15747]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084085411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 57664066483
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 57664066483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]
|
Facility
|
IP
|
$607.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$515.95 |
| Max. Negotiated Rate |
$588.79 |
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Health Management Network Commercial |
$515.95
|
| Rate for Payer: Health Management Network Commercial |
$381.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$404.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$546.30
|
| Rate for Payer: MDX Hawaii PPO |
$435.53
|
| Rate for Payer: MDX Hawaii PPO |
$588.79
|
|
|
CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]
|
Facility
|
OP
|
$607.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$588.79 |
| Rate for Payer: AlohaCare Medicaid |
$303.50
|
| Rate for Payer: AlohaCare Medicaid |
$224.50
|
| Rate for Payer: AlohaCare Medicare |
$341.24
|
| Rate for Payer: AlohaCare Medicare |
$461.32
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Devoted Health Medicare |
$377.16
|
| Rate for Payer: Devoted Health Medicare |
$509.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$461.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$341.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$426.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$576.65
|
| Rate for Payer: Health Management Network Commercial |
$515.95
|
| Rate for Payer: Health Management Network Commercial |
$381.65
|
| Rate for Payer: Humana Medicare |
$461.32
|
| Rate for Payer: Humana Medicare |
$341.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$404.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$546.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$228.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$309.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$341.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$461.32
|
| Rate for Payer: MDX Hawaii PPO |
$588.79
|
| Rate for Payer: MDX Hawaii PPO |
$435.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$341.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$461.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$461.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$341.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$269.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$364.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$461.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$341.24
|
| Rate for Payer: University Health Alliance Commercial |
$442.44
|
| Rate for Payer: University Health Alliance Commercial |
$327.28
|
|
|
CASPOFUNGIN 70 MG INTRAVENOUS SOLUTION [29568]
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$161.50 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
|
|
CASPOFUNGIN 70 MG INTRAVENOUS SOLUTION [29568]
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: AlohaCare Medicaid |
$95.00
|
| Rate for Payer: AlohaCare Medicare |
$144.40
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Devoted Health Medicare |
$159.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$144.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$180.50
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Humana Medicare |
$144.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.40
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$144.40
|
| Rate for Payer: University Health Alliance Commercial |
$138.49
|
|
|
CASPOFUNGIN ACETATE 50 MG/10ML IV (WET SOLR VIAL) [43029567]
|
Facility
|
IP
|
$1,820.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,547.00 |
| Max. Negotiated Rate |
$1,765.40 |
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Health Management Network Commercial |
$515.95
|
| Rate for Payer: Health Management Network Commercial |
$1,547.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,638.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$546.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,765.40
|
| Rate for Payer: MDX Hawaii PPO |
$588.79
|
|
|
CASPOFUNGIN ACETATE 50 MG/10ML IV (WET SOLR VIAL) [43029567]
|
Facility
|
OP
|
$607.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$588.79 |
| Rate for Payer: AlohaCare Medicaid |
$303.50
|
| Rate for Payer: AlohaCare Medicaid |
$910.00
|
| Rate for Payer: AlohaCare Medicare |
$1,383.20
|
| Rate for Payer: AlohaCare Medicare |
$461.32
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Cash Price |
$364.20
|
| Rate for Payer: Devoted Health Medicare |
$1,528.80
|
| Rate for Payer: Devoted Health Medicare |
$509.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,383.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$461.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,729.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$576.65
|
| Rate for Payer: Health Management Network Commercial |
$1,547.00
|
| Rate for Payer: Health Management Network Commercial |
$515.95
|
| Rate for Payer: Humana Medicare |
$1,383.20
|
| Rate for Payer: Humana Medicare |
$461.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$546.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,638.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$928.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$309.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,383.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$461.32
|
| Rate for Payer: MDX Hawaii PPO |
$1,765.40
|
| Rate for Payer: MDX Hawaii PPO |
$588.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$461.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,383.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,383.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$461.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,092.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$364.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$461.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,383.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,326.60
|
| Rate for Payer: University Health Alliance Commercial |
$442.44
|
|
|
CASPOFUNGIN ACETATE 70 MG/10ML IV (WET SOLR VIAL) [43029568]
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: AlohaCare Medicaid |
$68.00
|
| Rate for Payer: AlohaCare Medicaid |
$95.00
|
| Rate for Payer: AlohaCare Medicare |
$144.40
|
| Rate for Payer: AlohaCare Medicare |
$103.36
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Devoted Health Medicare |
$114.24
|
| Rate for Payer: Devoted Health Medicare |
$159.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$144.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$180.50
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Humana Medicare |
$103.36
|
| Rate for Payer: Humana Medicare |
$144.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.40
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$144.40
|
| Rate for Payer: University Health Alliance Commercial |
$99.13
|
| Rate for Payer: University Health Alliance Commercial |
$138.49
|
|
|
CASPOFUNGIN ACETATE 70 MG/10ML IV (WET SOLR VIAL) [43029568]
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS J0637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.60 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
|
|
CASSETTE IRRIG 5400-050-001
|
Facility
|
OP
|
$245.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: AlohaCare Medicaid |
$122.50
|
| Rate for Payer: AlohaCare Medicare |
$186.20
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Devoted Health Medicare |
$205.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$232.75
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Humana Medicare |
$186.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.20
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.20
|
| Rate for Payer: University Health Alliance Commercial |
$178.58
|
|
|
CASSETTE IRRIG 5400-050-001
|
Facility
|
IP
|
$245.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
|
|
CATH 10FR DRAINAGE APD
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$388.00 |
| Rate for Payer: AlohaCare Medicaid |
$200.00
|
| Rate for Payer: AlohaCare Medicare |
$304.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Devoted Health Medicare |
$336.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$304.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$380.00
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Humana Medicare |
$304.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$204.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$304.00
|
| Rate for Payer: MDX Hawaii PPO |
$388.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$304.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$304.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$304.00
|
| Rate for Payer: University Health Alliance Commercial |
$291.56
|
|
|
CATH 10FR DRAINAGE APD
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$340.00 |
| Max. Negotiated Rate |
$388.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$360.00
|
| Rate for Payer: MDX Hawaii PPO |
$388.00
|
|
|
CATH 10FR MALECOT
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
CATH 10FR MALECOT
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Ohana Health Plan Medicare |
$111.72
|
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$111.72
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$123.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$111.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.72
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.72
|
| Rate for Payer: University Health Alliance Commercial |
$107.15
|
|
|
CATH 10X4 ERCP BDC HURRICANE
|
Facility
|
OP
|
$898.00
|
|
|
Service Code
|
HCPCS C1726
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$449.00 |
| Max. Negotiated Rate |
$871.06 |
| Rate for Payer: AlohaCare Medicaid |
$449.00
|
| Rate for Payer: AlohaCare Medicare |
$682.48
|
| Rate for Payer: Cash Price |
$538.80
|
| Rate for Payer: Devoted Health Medicare |
$754.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$682.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$853.10
|
| Rate for Payer: Health Management Network Commercial |
$763.30
|
| Rate for Payer: Humana Medicare |
$682.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$808.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$457.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$682.48
|
| Rate for Payer: MDX Hawaii PPO |
$871.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$682.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$682.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$682.48
|
| Rate for Payer: University Health Alliance Commercial |
$654.55
|
|
|
CATH 10X4 ERCP BDC HURRICANE
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
HCPCS C1726
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$763.30 |
| Max. Negotiated Rate |
$871.06 |
| Rate for Payer: Cash Price |
$538.80
|
| Rate for Payer: Health Management Network Commercial |
$763.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$808.20
|
| Rate for Payer: MDX Hawaii PPO |
$871.06
|
|
|
CATH 12FR DRAINAGE APD
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$340.00 |
| Max. Negotiated Rate |
$388.00 |
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$360.00
|
| Rate for Payer: MDX Hawaii PPO |
$388.00
|
|
|
CATH 12FR DRAINAGE APD
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.00 |
| Max. Negotiated Rate |
$388.00 |
| Rate for Payer: AlohaCare Medicaid |
$200.00
|
| Rate for Payer: AlohaCare Medicare |
$304.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Devoted Health Medicare |
$336.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$304.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$380.00
|
| Rate for Payer: Health Management Network Commercial |
$340.00
|
| Rate for Payer: Humana Medicare |
$304.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$204.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$304.00
|
| Rate for Payer: MDX Hawaii PPO |
$388.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$304.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$304.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$304.00
|
| Rate for Payer: University Health Alliance Commercial |
$291.56
|
|
|
CATH 12FR MALECOT
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
CATH 12FR MALECOT
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS C1729
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$111.72
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$123.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$111.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.72
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.72
|
| Rate for Payer: University Health Alliance Commercial |
$107.15
|
|
|
CATH 12X16 HEMODIALYSIS DL
|
Facility
|
OP
|
$434.00
|
|
|
Service Code
|
HCPCS C1752
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$217.00 |
| Max. Negotiated Rate |
$420.98 |
| Rate for Payer: AlohaCare Medicaid |
$217.00
|
| Rate for Payer: AlohaCare Medicare |
$329.84
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Devoted Health Medicare |
$364.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$329.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$412.30
|
| Rate for Payer: Health Management Network Commercial |
$368.90
|
| Rate for Payer: Humana Medicare |
$329.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$390.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$221.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$329.84
|
| Rate for Payer: MDX Hawaii PPO |
$420.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$329.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$329.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$329.84
|
| Rate for Payer: University Health Alliance Commercial |
$316.34
|
|
|
CATH 12X16 HEMODIALYSIS DL
|
Facility
|
IP
|
$434.00
|
|
|
Service Code
|
HCPCS C1752
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$368.90 |
| Max. Negotiated Rate |
$420.98 |
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Health Management Network Commercial |
$368.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$390.60
|
| Rate for Payer: MDX Hawaii PPO |
$420.98
|
|
