|
INTRO PERCUTANEOUS CATH KIT 8F
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$329.80 |
| Rate for Payer: AlohaCare Medicaid |
$170.00
|
| Rate for Payer: AlohaCare Medicare |
$105.40
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Devoted Health Medicare |
$115.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$105.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$323.00
|
| Rate for Payer: Health Management Network Commercial |
$289.00
|
| Rate for Payer: Humana Medicare |
$105.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$173.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$105.40
|
| Rate for Payer: MDX Hawaii PPO |
$329.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$105.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$105.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$105.40
|
| Rate for Payer: University Health Alliance Commercial |
$247.83
|
|
|
INTRO PERCUTANEOUS CATH KIT 8F
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$289.00 |
| Max. Negotiated Rate |
$329.80 |
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Health Management Network Commercial |
$289.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$306.00
|
| Rate for Payer: MDX Hawaii PPO |
$329.80
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [111216]
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
NDC 38779059805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.60 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [111216]
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
NDC 38779059805
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.16 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: AlohaCare Medicaid |
$68.00
|
| Rate for Payer: AlohaCare Medicare |
$42.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Devoted Health Medicare |
$46.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.20
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Humana Medicare |
$42.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.16
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.16
|
| Rate for Payer: University Health Alliance Commercial |
$99.13
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: AlohaCare Medicaid |
$111.50
|
| Rate for Payer: AlohaCare Medicaid |
$222.50
|
| Rate for Payer: AlohaCare Medicare |
$69.13
|
| Rate for Payer: AlohaCare Medicare |
$137.95
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Devoted Health Medicare |
$151.30
|
| Rate for Payer: Devoted Health Medicare |
$75.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$137.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$422.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$211.85
|
| Rate for Payer: Health Management Network Commercial |
$189.55
|
| Rate for Payer: Health Management Network Commercial |
$378.25
|
| Rate for Payer: Humana Medicare |
$69.13
|
| Rate for Payer: Humana Medicare |
$137.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$400.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$226.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$113.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$137.95
|
| Rate for Payer: MDX Hawaii PPO |
$216.31
|
| Rate for Payer: MDX Hawaii PPO |
$431.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$137.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$137.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$137.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.13
|
| Rate for Payer: University Health Alliance Commercial |
$324.36
|
| Rate for Payer: University Health Alliance Commercial |
$162.54
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$189.55 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Health Management Network Commercial |
$189.55
|
| Rate for Payer: Health Management Network Commercial |
$378.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$400.50
|
| Rate for Payer: MDX Hawaii PPO |
$431.65
|
| Rate for Payer: MDX Hawaii PPO |
$216.31
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]
|
Facility
|
OP
|
$2,193.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$2,127.21 |
| Rate for Payer: AlohaCare Medicaid |
$1,096.50
|
| Rate for Payer: AlohaCare Medicaid |
$278.00
|
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicare |
$172.36
|
| Rate for Payer: AlohaCare Medicare |
$679.83
|
| Rate for Payer: AlohaCare Medicare |
$60.45
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cash Price |
$1,315.80
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cash Price |
$1,315.80
|
| Rate for Payer: Devoted Health Medicare |
$189.04
|
| Rate for Payer: Devoted Health Medicare |
$745.62
|
| Rate for Payer: Devoted Health Medicare |
$66.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$679.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,083.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$528.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Health Management Network Commercial |
$472.60
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Health Management Network Commercial |
$1,864.05
|
| Rate for Payer: Humana Medicare |
$172.36
|
| Rate for Payer: Humana Medicare |
$679.83
|
| Rate for Payer: Humana Medicare |
$60.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,973.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$500.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$283.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,118.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$679.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.36
|
| Rate for Payer: MDX Hawaii PPO |
$539.32
|
| Rate for Payer: MDX Hawaii PPO |
$2,127.21
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$679.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$679.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$679.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.36
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
| Rate for Payer: University Health Alliance Commercial |
$1,598.48
|
| Rate for Payer: University Health Alliance Commercial |
$405.27
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [119842]
|
Facility
|
IP
|
$556.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$472.60 |
| Max. Negotiated Rate |
$539.32 |
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cash Price |
$1,315.80
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Health Management Network Commercial |
$472.60
|
| Rate for Payer: Health Management Network Commercial |
$1,864.05
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,973.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$500.40
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: MDX Hawaii PPO |
$2,127.21
|
| Rate for Payer: MDX Hawaii PPO |
$539.32
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
OP
|
$2,226.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$2,159.22 |
| Rate for Payer: AlohaCare Medicaid |
$1,113.00
|
| Rate for Payer: AlohaCare Medicaid |
$212.00
|
| Rate for Payer: AlohaCare Medicare |
$131.44
|
| Rate for Payer: AlohaCare Medicare |
$690.06
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cash Price |
$1,335.60
|
| Rate for Payer: Cash Price |
$1,335.60
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Devoted Health Medicare |
$144.16
|
| Rate for Payer: Devoted Health Medicare |
$756.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$690.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$402.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,114.70
|
| Rate for Payer: Health Management Network Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$360.40
|
| Rate for Payer: Humana Medicare |
$131.44
|
| Rate for Payer: Humana Medicare |
$690.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,003.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$381.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$216.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,135.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$690.06
|
| Rate for Payer: MDX Hawaii PPO |
$411.28
|
| Rate for Payer: MDX Hawaii PPO |
$2,159.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$690.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$690.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$690.06
|
| Rate for Payer: University Health Alliance Commercial |
$1,622.53
|
| Rate for Payer: University Health Alliance Commercial |
$309.05
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
IP
|
$424.00
|
|
|
Service Code
|
HCPCS Q9967
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$360.40 |
| Max. Negotiated Rate |
$411.28 |
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cash Price |
$1,335.60
|
| Rate for Payer: Health Management Network Commercial |
$360.40
|
| Rate for Payer: Health Management Network Commercial |
$1,892.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$381.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,003.40
|
| Rate for Payer: MDX Hawaii PPO |
$411.28
|
| Rate for Payer: MDX Hawaii PPO |
$2,159.22
|
|
|
IOLENS 6.0 PRELOADED
|
Facility
|
IP
|
$563.00
|
|
|
Service Code
|
HCPCS V2632
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$315.28 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$394.10
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: University Health Alliance Commercial |
$315.28
|
|
|
IOLENS 6.0 PRELOADED
|
Facility
|
OP
|
$563.00
|
|
|
Service Code
|
HCPCS V2632
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$174.53 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: AlohaCare Medicaid |
$281.50
|
| Rate for Payer: AlohaCare Medicare |
$174.53
|
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Devoted Health Medicare |
$191.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$394.10
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Humana Medicare |
$174.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$287.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.53
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$311.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.53
|
| Rate for Payer: University Health Alliance Commercial |
$315.28
|
|
|
IOLENS DIOP 10.0 SN60WF10.0
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS V2632
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$232.50 |
| Max. Negotiated Rate |
$727.50 |
| Rate for Payer: AlohaCare Medicaid |
$375.00
|
| Rate for Payer: AlohaCare Medicare |
$232.50
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Devoted Health Medicare |
$255.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$525.00
|
| Rate for Payer: Health Management Network Commercial |
$637.50
|
| Rate for Payer: Humana Medicare |
$232.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$675.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$382.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.50
|
| Rate for Payer: MDX Hawaii PPO |
$727.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$311.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.50
|
| Rate for Payer: University Health Alliance Commercial |
$420.00
|
|
|
IOLENS DIOP 10.0 SN60WF10.0
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS V2632
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$727.50 |
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$525.00
|
| Rate for Payer: Health Management Network Commercial |
$637.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$675.00
|
| Rate for Payer: MDX Hawaii PPO |
$727.50
|
| Rate for Payer: University Health Alliance Commercial |
$420.00
|
|
|
IOLENS DIOP 11.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 11.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 12.0 SN6AT3 12.0
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 12.0 SN6AT3 12.0
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 12.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 12.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 14.0 SN6AT8 14.0
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 14.0 SN6AT8 14.0
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 15.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 15.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 17.5 SN6AT7 17.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
