|
ILIAC EXTENDER ENDOPROSTHESIS
|
Facility
|
OP
|
$6,200.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,922.00 |
| Max. Negotiated Rate |
$6,014.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,100.00
|
| Rate for Payer: AlohaCare Medicare |
$1,922.00
|
| Rate for Payer: Cash Price |
$3,720.00
|
| Rate for Payer: Devoted Health Medicare |
$2,108.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,922.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,340.00
|
| Rate for Payer: Health Management Network Commercial |
$5,270.00
|
| Rate for Payer: Humana Medicare |
$1,922.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,580.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,162.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,922.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,014.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,922.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,922.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,922.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,472.00
|
|
|
ILIAC EXTENDER ENDOPROSTHESIS
|
Facility
|
IP
|
$6,200.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.00 |
| Max. Negotiated Rate |
$6,014.00 |
| Rate for Payer: Cash Price |
$3,720.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,340.00
|
| Rate for Payer: Health Management Network Commercial |
$5,270.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,580.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,014.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,472.00
|
|
|
ILIVIA 7 DEFIBRILLATOR 404625
|
Facility
|
OP
|
$33,900.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,509.00 |
| Max. Negotiated Rate |
$32,883.00 |
| Rate for Payer: AlohaCare Medicaid |
$16,950.00
|
| Rate for Payer: AlohaCare Medicare |
$10,509.00
|
| Rate for Payer: Cash Price |
$20,340.00
|
| Rate for Payer: Devoted Health Medicare |
$11,526.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,509.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23,730.00
|
| Rate for Payer: Health Management Network Commercial |
$28,815.00
|
| Rate for Payer: Humana Medicare |
$10,509.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,510.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17,289.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,509.00
|
| Rate for Payer: MDX Hawaii PPO |
$32,883.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,509.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,509.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,509.00
|
| Rate for Payer: University Health Alliance Commercial |
$18,984.00
|
|
|
ILIVIA 7 DEFIBRILLATOR 404625
|
Facility
|
IP
|
$33,900.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$18,984.00 |
| Max. Negotiated Rate |
$32,883.00 |
| Rate for Payer: Cash Price |
$20,340.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23,730.00
|
| Rate for Payer: Health Management Network Commercial |
$28,815.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,510.00
|
| Rate for Payer: MDX Hawaii PPO |
$32,883.00
|
| Rate for Payer: University Health Alliance Commercial |
$18,984.00
|
|
|
IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: AlohaCare Medicare |
$32.86
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: AlohaCare Medicare |
$25.73
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Devoted Health Medicare |
$28.22
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$36.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$32.86
|
| Rate for Payer: Humana Medicare |
$25.73
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$77.26
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: AlohaCare Medicare |
$25.73
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$28.22
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Humana Medicare |
$25.73
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
IMMOBILIZER KNEE 16
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$43.71 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicare |
$43.71
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Devoted Health Medicare |
$47.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.70
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$43.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.71
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.71
|
| Rate for Payer: University Health Alliance Commercial |
$78.96
|
|
|
IMMOBILIZER KNEE 16
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$78.96 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.70
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: University Health Alliance Commercial |
$78.96
|
|
|
IMMOBILIZER KNEE 20
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$87.51 |
| Rate for Payer: AlohaCare Medicaid |
$43.50
|
| Rate for Payer: AlohaCare Medicare |
$26.97
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Devoted Health Medicare |
$29.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.90
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Humana Medicare |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.97
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.97
|
| Rate for Payer: University Health Alliance Commercial |
$48.72
|
|
|
IMMOBILIZER KNEE 20
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.90
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: University Health Alliance Commercial |
$48.72
|
|
|
IMMOBILIZER KNEE 22
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.10
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: University Health Alliance Commercial |
$57.68
|
|
|
IMMOBILIZER KNEE 22
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: AlohaCare Medicaid |
$51.50
|
| Rate for Payer: AlohaCare Medicare |
$31.93
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Devoted Health Medicare |
$35.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.10
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Humana Medicare |
$31.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.93
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.93
|
| Rate for Payer: University Health Alliance Commercial |
$57.68
|
|
|
IMMOBILIZER KNEE 24
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.14 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicare |
$29.14
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Devoted Health Medicare |
$31.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.80
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Humana Medicare |
$29.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.14
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.14
|
| Rate for Payer: University Health Alliance Commercial |
$52.64
|
|
|
IMMOBILIZER KNEE 24
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.64 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.80
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: University Health Alliance Commercial |
$52.64
|
|
|
IMPELLA CP
|
Facility
|
OP
|
$56,000.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17,360.00 |
| Max. Negotiated Rate |
$54,320.00 |
| Rate for Payer: AlohaCare Medicaid |
$28,000.00
|
| Rate for Payer: AlohaCare Medicare |
$17,360.00
|
| Rate for Payer: Cash Price |
$33,600.00
|
| Rate for Payer: Devoted Health Medicare |
$19,040.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39,200.00
|
| Rate for Payer: Health Management Network Commercial |
$47,600.00
|
| Rate for Payer: Humana Medicare |
$17,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$50,400.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28,560.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$17,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$54,320.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$17,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$17,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$31,360.00
|
|
|
IMPELLA CP
|
Facility
|
IP
|
$56,000.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31,360.00 |
| Max. Negotiated Rate |
$54,320.00 |
| Rate for Payer: Cash Price |
$33,600.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39,200.00
|
| Rate for Payer: Health Management Network Commercial |
$47,600.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$50,400.00
|
| Rate for Payer: MDX Hawaii PPO |
$54,320.00
|
| Rate for Payer: University Health Alliance Commercial |
$31,360.00
|
|
|
IMPELLA LP COMPANION SHEATH 7F
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$743.75 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$787.50
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
|
|
IMPELLA LP COMPANION SHEATH 7F
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.25 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: AlohaCare Medicaid |
$437.50
|
| Rate for Payer: AlohaCare Medicare |
$271.25
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Devoted Health Medicare |
$297.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$271.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$831.25
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Humana Medicare |
$271.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$787.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$446.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$271.25
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$271.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$271.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$271.25
|
| Rate for Payer: University Health Alliance Commercial |
$637.79
|
|
|
IMPLAN .15X50X40 NASAL PERF
|
Facility
|
OP
|
$1,692.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.52 |
| Max. Negotiated Rate |
$1,641.24 |
| Rate for Payer: AlohaCare Medicaid |
$846.00
|
| Rate for Payer: AlohaCare Medicare |
$524.52
|
| Rate for Payer: Cash Price |
$1,015.20
|
| Rate for Payer: Devoted Health Medicare |
$575.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$524.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,184.40
|
| Rate for Payer: Health Management Network Commercial |
$1,438.20
|
| Rate for Payer: Humana Medicare |
$524.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$862.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$524.52
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$524.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$524.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$524.52
|
| Rate for Payer: University Health Alliance Commercial |
$947.52
|
|
|
IMPLAN .15X50X40 NASAL PERF
|
Facility
|
IP
|
$1,692.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$947.52 |
| Max. Negotiated Rate |
$1,641.24 |
| Rate for Payer: Cash Price |
$1,015.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,184.40
|
| Rate for Payer: Health Management Network Commercial |
$1,438.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.24
|
| Rate for Payer: University Health Alliance Commercial |
$947.52
|
|
|
IMPLAN .25X40X50 NASAL FLEX
|
Facility
|
OP
|
$1,692.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.52 |
| Max. Negotiated Rate |
$1,641.24 |
| Rate for Payer: AlohaCare Medicaid |
$846.00
|
| Rate for Payer: AlohaCare Medicare |
$524.52
|
| Rate for Payer: Cash Price |
$1,015.20
|
| Rate for Payer: Devoted Health Medicare |
$575.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$524.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,184.40
|
| Rate for Payer: Health Management Network Commercial |
$1,438.20
|
| Rate for Payer: Humana Medicare |
$524.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$862.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$524.52
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$524.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$524.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$524.52
|
| Rate for Payer: University Health Alliance Commercial |
$947.52
|
|
|
IMPLAN .25X40X50 NASAL FLEX
|
Facility
|
IP
|
$1,692.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$947.52 |
| Max. Negotiated Rate |
$1,641.24 |
| Rate for Payer: Cash Price |
$1,015.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,184.40
|
| Rate for Payer: Health Management Network Commercial |
$1,438.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.24
|
| Rate for Payer: University Health Alliance Commercial |
$947.52
|
|
|
IMPLAN BUCKET HANDLE .4X4.25
|
Facility
|
OP
|
$930.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$288.30 |
| Max. Negotiated Rate |
$902.10 |
| Rate for Payer: AlohaCare Medicaid |
$465.00
|
| Rate for Payer: AlohaCare Medicare |
$288.30
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Devoted Health Medicare |
$316.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$288.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$651.00
|
| Rate for Payer: Health Management Network Commercial |
$790.50
|
| Rate for Payer: Humana Medicare |
$288.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$837.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$474.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$288.30
|
| Rate for Payer: MDX Hawaii PPO |
$902.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$288.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$288.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$288.30
|
| Rate for Payer: University Health Alliance Commercial |
$520.80
|
|
