|
INSULIN ASPART U-100 100 UNIT/ML SUBCUTANEOUS SOLUTION [183769]
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [186530]
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 00088221905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [186530]
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 00088221901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [28282]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 00088222033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [28282]
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
NDC 00955172901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.25 |
| Max. Negotiated Rate |
$198.85 |
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Health Management Network Commercial |
$174.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.50
|
| Rate for Payer: MDX Hawaii PPO |
$198.85
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicaid |
$54.00
|
| Rate for Payer: AlohaCare Medicare |
$33.48
|
| Rate for Payer: AlohaCare Medicare |
$35.96
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Devoted Health Medicare |
$36.72
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.60
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Humana Medicare |
$35.96
|
| Rate for Payer: Humana Medicare |
$33.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.96
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.96
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
| Rate for Payer: University Health Alliance Commercial |
$78.72
|
|
|
INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP [10286]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.80 |
| Max. Negotiated Rate |
$104.76 |
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
|
|
INSULIN LISPRO 100 UNIT/ML IJ SOLN (ADMELOG) [440184255]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: AlohaCare Medicaid |
$59.00
|
| Rate for Payer: AlohaCare Medicare |
$36.58
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Devoted Health Medicare |
$40.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Humana Medicare |
$36.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.58
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.58
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
INSULIN LISPRO 100 UNIT/ML IJ SOLN (ADMELOG) [440184255]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP [70693]
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: AlohaCare Medicaid |
$77.00
|
| Rate for Payer: AlohaCare Medicare |
$47.74
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Devoted Health Medicare |
$52.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$146.30
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Humana Medicare |
$47.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.74
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.74
|
| Rate for Payer: University Health Alliance Commercial |
$112.25
|
|
|
INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP [70693]
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [124854]
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$82.45 |
| Rate for Payer: AlohaCare Medicaid |
$42.50
|
| Rate for Payer: AlohaCare Medicare |
$26.35
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Devoted Health Medicare |
$28.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$80.75
|
| Rate for Payer: Health Management Network Commercial |
$72.25
|
| Rate for Payer: Humana Medicare |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$82.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.35
|
| Rate for Payer: University Health Alliance Commercial |
$61.96
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN [124854]
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.25 |
| Max. Negotiated Rate |
$82.45 |
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$72.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.50
|
| Rate for Payer: MDX Hawaii PPO |
$82.45
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicare |
$35.96
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Humana Medicare |
$35.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.96
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.96
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION [10284]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J1815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [168938]
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 00338012612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
|
|
INSULIN REGULAR 100 UNIT/ML SQ GLUCOSE CORRECTION SCALE [400932]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
|
|
INSULIN REGULAR 100 UNIT/ML SQ GLUCOSE CORRECTION SCALE [400932]
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicare |
$35.96
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Humana Medicare |
$35.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.96
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.96
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION [10289]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J1817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicare |
$35.96
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$35.96
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.96
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
INTEGRA BILAYER MATRX #BMW2021
|
Facility
|
IP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C9363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,950.00 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
|
|
INTEGRA BILAYER MATRX #BMW2021
|
Facility
|
OP
|
$7,000.00
|
|
|
Service Code
|
HCPCS C9363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.93 |
| Max. Negotiated Rate |
$6,790.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,500.00
|
| Rate for Payer: AlohaCare Medicare |
$2,170.00
|
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Cash Price |
$4,200.00
|
| Rate for Payer: Devoted Health Medicare |
$2,380.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$158.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,170.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,650.00
|
| Rate for Payer: Health Management Network Commercial |
$5,950.00
|
| Rate for Payer: Humana Medicare |
$2,170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,300.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,570.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,170.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,790.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,170.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,170.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,200.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,170.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,102.30
|
|
|
INTEGRA BILAYER MATRX #BMW4051
|
Facility
|
IP
|
$10,898.00
|
|
|
Service Code
|
HCPCS C9363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,263.30 |
| Max. Negotiated Rate |
$10,571.06 |
| Rate for Payer: Cash Price |
$6,538.80
|
| Rate for Payer: Health Management Network Commercial |
$9,263.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,808.20
|
| Rate for Payer: MDX Hawaii PPO |
$10,571.06
|
|
|
INTEGRA BILAYER MATRX #BMW4051
|
Facility
|
OP
|
$10,898.00
|
|
|
Service Code
|
HCPCS C9363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.93 |
| Max. Negotiated Rate |
$10,571.06 |
| Rate for Payer: AlohaCare Medicaid |
$5,449.00
|
| Rate for Payer: AlohaCare Medicare |
$3,378.38
|
| Rate for Payer: Cash Price |
$6,538.80
|
| Rate for Payer: Cash Price |
$6,538.80
|
| Rate for Payer: Devoted Health Medicare |
$3,705.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$158.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,378.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,353.10
|
| Rate for Payer: Health Management Network Commercial |
$9,263.30
|
| Rate for Payer: Humana Medicare |
$3,378.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,808.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,557.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,378.38
|
| Rate for Payer: MDX Hawaii PPO |
$10,571.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,378.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,378.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,538.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,378.38
|
| Rate for Payer: University Health Alliance Commercial |
$7,943.55
|
|
|
INTEGRATED PORT ALLOX2-FH12SE
|
Facility
|
IP
|
$3,300.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,848.00 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Cash Price |
$1,980.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,310.00
|
| Rate for Payer: Health Management Network Commercial |
$2,805.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,970.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,201.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,848.00
|
|
