|
DILATORS COONS TAPER 16FR,20CM
|
Facility
|
OP
|
$91.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: AlohaCare Medicaid |
$45.50
|
| Rate for Payer: AlohaCare Medicare |
$28.21
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Devoted Health Medicare |
$30.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$77.35
|
| Rate for Payer: Humana Medicare |
$28.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.21
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.21
|
| Rate for Payer: University Health Alliance Commercial |
$66.33
|
|
|
DILATORS COONS TAPER 16FR,20CM
|
Facility
|
IP
|
$91.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Health Management Network Commercial |
$77.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.90
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
|
|
DILATOR SET AMPLATZ RENAL
|
Facility
|
OP
|
$824.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.44 |
| Max. Negotiated Rate |
$799.28 |
| Rate for Payer: AlohaCare Medicaid |
$412.00
|
| Rate for Payer: AlohaCare Medicare |
$255.44
|
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Devoted Health Medicare |
$280.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$255.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$782.80
|
| Rate for Payer: Health Management Network Commercial |
$700.40
|
| Rate for Payer: Humana Medicare |
$255.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$741.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$420.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$255.44
|
| Rate for Payer: MDX Hawaii PPO |
$799.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$255.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$255.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$255.44
|
| Rate for Payer: University Health Alliance Commercial |
$600.61
|
|
|
DILATOR SET AMPLATZ RENAL
|
Facility
|
IP
|
$824.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$700.40 |
| Max. Negotiated Rate |
$799.28 |
| Rate for Payer: Cash Price |
$494.40
|
| Rate for Payer: Health Management Network Commercial |
$700.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$741.60
|
| Rate for Payer: MDX Hawaii PPO |
$799.28
|
|
|
DILATOR SET S-CURVE
|
Facility
|
OP
|
$839.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$260.09 |
| Max. Negotiated Rate |
$813.83 |
| Rate for Payer: AlohaCare Medicaid |
$419.50
|
| Rate for Payer: AlohaCare Medicare |
$260.09
|
| Rate for Payer: Cash Price |
$503.40
|
| Rate for Payer: Devoted Health Medicare |
$285.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$260.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$797.05
|
| Rate for Payer: Health Management Network Commercial |
$713.15
|
| Rate for Payer: Humana Medicare |
$260.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$755.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$427.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$260.09
|
| Rate for Payer: MDX Hawaii PPO |
$813.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$260.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$260.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$260.09
|
| Rate for Payer: University Health Alliance Commercial |
$611.55
|
|
|
DILATOR SET S-CURVE
|
Facility
|
IP
|
$839.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$713.15 |
| Max. Negotiated Rate |
$813.83 |
| Rate for Payer: Cash Price |
$503.40
|
| Rate for Payer: Health Management Network Commercial |
$713.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$755.10
|
| Rate for Payer: MDX Hawaii PPO |
$813.83
|
|
|
DILATOR/SHEATH 8-10FR
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.79 |
| Max. Negotiated Rate |
$202.73 |
| Rate for Payer: AlohaCare Medicaid |
$104.50
|
| Rate for Payer: AlohaCare Medicare |
$64.79
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Devoted Health Medicare |
$71.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.55
|
| Rate for Payer: Health Management Network Commercial |
$177.65
|
| Rate for Payer: Humana Medicare |
$64.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$188.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$106.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.79
|
| Rate for Payer: MDX Hawaii PPO |
$202.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.79
|
| Rate for Payer: University Health Alliance Commercial |
$152.34
|
|
|
DILATOR/SHEATH 8-10FR
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$177.65 |
| Max. Negotiated Rate |
$202.73 |
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$177.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$188.10
|
| Rate for Payer: MDX Hawaii PPO |
$202.73
|
|
|
DILTIAZEM 125 MG/125 ML (1 MG/ML) IN NS (SIMPLE) [4080053]
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 00004080015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687071711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687071701
|
|
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
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687071701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
DILTIAZEM 30 MG TABLET [2475]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687071711
|
|
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
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
NDC 00641601510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00641601310
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 70860030142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00641601410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
NDC 00641601501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00641601301
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687072801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00093031901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687072811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68682000710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687072801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00093031901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
