|
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$41,336.29
|
|
|
Service Code
|
MSDRG 434
|
| Min. Negotiated Rate |
$41,336.29 |
| Max. Negotiated Rate |
$41,336.29 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,336.29
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [119149]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 71288071206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [119149]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 71288071205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J9060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicaid |
$28.50
|
| Rate for Payer: AlohaCare Medicaid |
$76.00
|
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$39.99
|
| Rate for Payer: AlohaCare Medicare |
$52.08
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: AlohaCare Medicare |
$47.12
|
| Rate for Payer: AlohaCare Medicare |
$17.67
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Devoted Health Medicare |
$19.38
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Devoted Health Medicare |
$51.68
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| Rate for Payer: Devoted Health Medicare |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.55
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$129.20
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Humana Medicare |
$52.08
|
| Rate for Payer: Humana Medicare |
$47.12
|
| Rate for Payer: Humana Medicare |
$39.99
|
| Rate for Payer: Humana Medicare |
$17.67
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
| Rate for Payer: MDX Hawaii PPO |
$147.44
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.67
|
| Rate for Payer: University Health Alliance Commercial |
$41.55
|
| Rate for Payer: University Health Alliance Commercial |
$110.79
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [88376]
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS J9060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.20 |
| Max. Negotiated Rate |
$147.44 |
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$129.20
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$136.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$147.44
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [131501]
|
Facility
|
IP
|
$555.00
|
|
|
Service Code
|
HCPCS J9065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$471.75 |
| Max. Negotiated Rate |
$538.35 |
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Health Management Network Commercial |
$471.75
|
| Rate for Payer: Health Management Network Commercial |
$637.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$499.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$675.00
|
| Rate for Payer: MDX Hawaii PPO |
$727.50
|
| Rate for Payer: MDX Hawaii PPO |
$538.35
|
|
|
CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION [131501]
|
Facility
|
OP
|
$555.00
|
|
|
Service Code
|
HCPCS J9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.73 |
| Max. Negotiated Rate |
$538.35 |
| Rate for Payer: AlohaCare Medicaid |
$277.50
|
| Rate for Payer: AlohaCare Medicaid |
$375.00
|
| Rate for Payer: AlohaCare Medicare |
$232.50
|
| Rate for Payer: AlohaCare Medicare |
$172.05
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$333.00
|
| Rate for Payer: Devoted Health Medicare |
$188.70
|
| Rate for Payer: Devoted Health Medicare |
$255.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.73
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$527.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$712.50
|
| Rate for Payer: Health Management Network Commercial |
$637.50
|
| Rate for Payer: Health Management Network Commercial |
$471.75
|
| Rate for Payer: Humana Medicare |
$172.05
|
| Rate for Payer: Humana Medicare |
$232.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$499.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$675.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$382.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$283.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.50
|
| Rate for Payer: MDX Hawaii PPO |
$538.35
|
| Rate for Payer: MDX Hawaii PPO |
$727.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$450.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$333.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.50
|
| Rate for Payer: University Health Alliance Commercial |
$404.54
|
| Rate for Payer: University Health Alliance Commercial |
$546.67
|
|
|
CLAMP 4.0MM ADJUST DR #390.051
|
Facility
|
IP
|
$2,967.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,521.95 |
| Max. Negotiated Rate |
$2,877.99 |
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Health Management Network Commercial |
$2,521.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,670.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,877.99
|
|
|
CLAMP 4.0MM ADJUST DR #390.051
|
Facility
|
OP
|
$2,967.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$919.77 |
| Max. Negotiated Rate |
$2,877.99 |
| Rate for Payer: AlohaCare Medicaid |
$1,483.50
|
| Rate for Payer: AlohaCare Medicare |
$919.77
|
| Rate for Payer: Cash Price |
$1,780.20
|
| Rate for Payer: Devoted Health Medicare |
$1,008.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$919.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,818.65
|
| Rate for Payer: Health Management Network Commercial |
$2,521.95
|
| Rate for Payer: Humana Medicare |
$919.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,670.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,513.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$919.77
|
| Rate for Payer: MDX Hawaii PPO |
$2,877.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$919.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$919.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$919.77
|
| Rate for Payer: University Health Alliance Commercial |
$2,162.65
|
|
|
CLAMP 8MM/11MM COMBO #390.037
|
Facility
|
OP
|
$2,092.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$648.52 |
| Max. Negotiated Rate |
$2,029.24 |
| Rate for Payer: AlohaCare Medicaid |
$1,046.00
|
| Rate for Payer: AlohaCare Medicare |
$648.52
|
| Rate for Payer: Cash Price |
$1,255.20
|
| Rate for Payer: Devoted Health Medicare |
$711.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$648.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,987.40
|
| Rate for Payer: Health Management Network Commercial |
$1,778.20
|
| Rate for Payer: Humana Medicare |
$648.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,882.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,066.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$648.52
|
| Rate for Payer: MDX Hawaii PPO |
$2,029.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$648.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$648.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$648.52
|
| Rate for Payer: University Health Alliance Commercial |
$1,524.86
|
|
|
CLAMP 8MM/11MM COMBO #390.037
|
Facility
|
IP
|
$2,092.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,778.20 |
| Max. Negotiated Rate |
$2,029.24 |
| Rate for Payer: Cash Price |
$1,255.20
|
| Rate for Payer: Health Management Network Commercial |
$1,778.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,882.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,029.24
|
|
|
CLAMP COMBINATION LRG 390.005
|
Facility
|
IP
|
$2,524.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,145.40 |
| Max. Negotiated Rate |
$2,448.28 |
| Rate for Payer: Cash Price |
$1,514.40
|
| Rate for Payer: Health Management Network Commercial |
$2,145.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,271.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,448.28
|
|
|
CLAMP COMBINATION LRG 390.005
|
Facility
|
OP
|
$2,524.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$782.44 |
| Max. Negotiated Rate |
$2,448.28 |
| Rate for Payer: AlohaCare Medicaid |
$1,262.00
|
| Rate for Payer: AlohaCare Medicare |
$782.44
|
| Rate for Payer: Cash Price |
$1,514.40
|
| Rate for Payer: Devoted Health Medicare |
$858.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$782.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,397.80
|
| Rate for Payer: Health Management Network Commercial |
$2,145.40
|
| Rate for Payer: Humana Medicare |
$782.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,271.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,287.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$782.44
|
| Rate for Payer: MDX Hawaii PPO |
$2,448.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$782.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$782.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$782.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,839.74
|
|
|
CLAMP COMBINATION MED 390.031
|
Facility
|
OP
|
$2,054.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.74 |
| Max. Negotiated Rate |
$1,992.38 |
| Rate for Payer: AlohaCare Medicaid |
$1,027.00
|
| Rate for Payer: AlohaCare Medicare |
$636.74
|
| Rate for Payer: Cash Price |
$1,232.40
|
| Rate for Payer: Devoted Health Medicare |
$698.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$636.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,951.30
|
| Rate for Payer: Health Management Network Commercial |
$1,745.90
|
| Rate for Payer: Humana Medicare |
$636.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,848.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,047.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$636.74
|
| Rate for Payer: MDX Hawaii PPO |
$1,992.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$636.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$636.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$636.74
|
| Rate for Payer: University Health Alliance Commercial |
$1,497.16
|
|
|
CLAMP COMBINATION MED 390.031
|
Facility
|
IP
|
$2,054.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,745.90 |
| Max. Negotiated Rate |
$1,992.38 |
| Rate for Payer: Cash Price |
$1,232.40
|
| Rate for Payer: Health Management Network Commercial |
$1,745.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,848.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,992.38
|
|
|
CLAMP COVER MINIFIXATOR M138
|
Facility
|
OP
|
$270.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.70 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$83.70
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$91.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Humana Medicare |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.70
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.70
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
CLAMP COVER MINIFIXATOR M138
|
Facility
|
IP
|
$270.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
|
|
CLAMP COVER MINIRAIL M203
|
Facility
|
IP
|
$288.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: Health Management Network Commercial |
$244.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.20
|
| Rate for Payer: MDX Hawaii PPO |
$279.36
|
|
|
CLAMP COVER MINIRAIL M203
|
Facility
|
OP
|
$288.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$89.28 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: AlohaCare Medicaid |
$144.00
|
| Rate for Payer: AlohaCare Medicare |
$89.28
|
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: Devoted Health Medicare |
$97.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$273.60
|
| Rate for Payer: Health Management Network Commercial |
$244.80
|
| Rate for Payer: Humana Medicare |
$89.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$146.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.28
|
| Rate for Payer: MDX Hawaii PPO |
$279.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.28
|
| Rate for Payer: University Health Alliance Commercial |
$209.92
|
|
|
CLAMP DYNAMIZATION LRG 390.006
|
Facility
|
IP
|
$713.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$606.05 |
| Max. Negotiated Rate |
$691.61 |
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Health Management Network Commercial |
$606.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$641.70
|
| Rate for Payer: MDX Hawaii PPO |
$691.61
|
|
|
CLAMP DYNAMIZATION LRG 390.006
|
Facility
|
OP
|
$713.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.03 |
| Max. Negotiated Rate |
$691.61 |
| Rate for Payer: AlohaCare Medicaid |
$356.50
|
| Rate for Payer: AlohaCare Medicare |
$221.03
|
| Rate for Payer: Cash Price |
$427.80
|
| Rate for Payer: Devoted Health Medicare |
$242.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$221.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$677.35
|
| Rate for Payer: Health Management Network Commercial |
$606.05
|
| Rate for Payer: Humana Medicare |
$221.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$641.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$221.03
|
| Rate for Payer: MDX Hawaii PPO |
$691.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$221.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$221.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$221.03
|
| Rate for Payer: University Health Alliance Commercial |
$519.71
|
|
|
CLAMP MED PIN 4-POS 390.026
|
Facility
|
OP
|
$2,193.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$679.83 |
| Max. Negotiated Rate |
$2,127.21 |
| Rate for Payer: AlohaCare Medicaid |
$1,096.50
|
| Rate for Payer: AlohaCare Medicare |
$679.83
|
| Rate for Payer: Cash Price |
$1,315.80
|
| Rate for Payer: Devoted Health Medicare |
$745.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$679.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,083.35
|
| Rate for Payer: Health Management Network Commercial |
$1,864.05
|
| Rate for Payer: Humana Medicare |
$679.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,973.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,118.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$679.83
|
| Rate for Payer: MDX Hawaii PPO |
$2,127.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$679.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$679.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$679.83
|
| Rate for Payer: University Health Alliance Commercial |
$1,598.48
|
|
|
CLAMP MED PIN 4-POS 390.026
|
Facility
|
IP
|
$2,193.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,864.05 |
| Max. Negotiated Rate |
$2,127.21 |
| Rate for Payer: Cash Price |
$1,315.80
|
| Rate for Payer: Health Management Network Commercial |
$1,864.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,973.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,127.21
|
|
|
CLAMP MULTI-PIN 4-POS 390.004
|
Facility
|
OP
|
$2,700.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$837.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,350.00
|
| Rate for Payer: AlohaCare Medicare |
$837.00
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Devoted Health Medicare |
$918.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,565.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Humana Medicare |
$837.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,377.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,968.03
|
|
|
CLAMP MULTI-PIN 4-POS 390.004
|
Facility
|
IP
|
$2,700.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,295.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
|
