|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J2543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$21.39
|
| Rate for Payer: AlohaCare Medicare |
$7.44
|
| Rate for Payer: AlohaCare Medicare |
$17.05
|
| Rate for Payer: AlohaCare Medicare |
$18.29
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$20.06
|
| Rate for Payer: Devoted Health Medicare |
$18.70
|
| Rate for Payer: Devoted Health Medicare |
$23.46
|
| Rate for Payer: Devoted Health Medicare |
$8.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$7.44
|
| Rate for Payer: Humana Medicare |
$18.29
|
| Rate for Payer: Humana Medicare |
$17.05
|
| Rate for Payer: Humana Medicare |
$21.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.05
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.05
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
| Rate for Payer: University Health Alliance Commercial |
$50.29
|
|
|
PLAT DHS 135D/6H/110MM 281.160
|
Facility
|
IP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 135D/6H/110MM 281.160
|
Facility
|
OP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$753.30 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,215.00
|
| Rate for Payer: AlohaCare Medicare |
$753.30
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Devoted Health Medicare |
$826.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$753.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Humana Medicare |
$753.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,239.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$753.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$753.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$753.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$753.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 140D 6H 110MM 281.260
|
Facility
|
OP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$753.30 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,215.00
|
| Rate for Payer: AlohaCare Medicare |
$753.30
|
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Devoted Health Medicare |
$826.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$753.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Humana Medicare |
$753.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,239.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$753.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$753.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$753.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$753.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 140D 6H 110MM 281.260
|
Facility
|
IP
|
$2,430.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.80 |
| Max. Negotiated Rate |
$2,357.10 |
| Rate for Payer: Cash Price |
$1,458.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,701.00
|
| Rate for Payer: Health Management Network Commercial |
$2,065.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,187.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,357.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,360.80
|
|
|
PLAT DHS 145D/6H/110MM 281.360
|
Facility
|
IP
|
$2,001.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.56 |
| Max. Negotiated Rate |
$1,940.97 |
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.70
|
| Rate for Payer: Health Management Network Commercial |
$1,700.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.97
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.56
|
|
|
PLAT DHS 145D/6H/110MM 281.360
|
Facility
|
OP
|
$2,001.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$620.31 |
| Max. Negotiated Rate |
$1,940.97 |
| Rate for Payer: AlohaCare Medicaid |
$1,000.50
|
| Rate for Payer: AlohaCare Medicare |
$620.31
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Devoted Health Medicare |
$680.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$620.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.70
|
| Rate for Payer: Health Management Network Commercial |
$1,700.85
|
| Rate for Payer: Humana Medicare |
$620.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$620.31
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$620.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$620.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$620.31
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.56
|
|
|
PLATE 10 HOLE 629550S
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.60 |
| Max. Negotiated Rate |
$1,998.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,030.00
|
| Rate for Payer: AlohaCare Medicare |
$638.60
|
| Rate for Payer: Cash Price |
$1,236.00
|
| Rate for Payer: Devoted Health Medicare |
$700.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$638.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,442.00
|
| Rate for Payer: Health Management Network Commercial |
$1,751.00
|
| Rate for Payer: Humana Medicare |
$638.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,854.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,050.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$638.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,998.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$638.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$638.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$638.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,153.60
|
|
|
PLATE 10 HOLE 629550S
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,153.60 |
| Max. Negotiated Rate |
$1,998.20 |
| Rate for Payer: Cash Price |
$1,236.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,442.00
|
| Rate for Payer: Health Management Network Commercial |
$1,751.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,854.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,998.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,153.60
|
|
|
PLATE 126MM 10H
|
Facility
|
IP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,246.00 |
| Max. Negotiated Rate |
$2,158.25 |
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,557.50
|
| Rate for Payer: Health Management Network Commercial |
$1,891.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,002.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,158.25
|
| Rate for Payer: University Health Alliance Commercial |
$1,246.00
|
|
|
PLATE 126MM 10H
|
Facility
|
OP
|
$2,225.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$689.75 |
| Max. Negotiated Rate |
$2,158.25 |
| Rate for Payer: AlohaCare Medicaid |
$1,112.50
|
| Rate for Payer: AlohaCare Medicare |
$689.75
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Devoted Health Medicare |
$756.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$689.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,557.50
|
| Rate for Payer: Health Management Network Commercial |
$1,891.25
|
| Rate for Payer: Humana Medicare |
$689.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,002.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,134.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$689.75
|
| Rate for Payer: MDX Hawaii PPO |
$2,158.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$689.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$689.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$689.75
|
| Rate for Payer: University Health Alliance Commercial |
$1,246.00
|
|
|
PLATE 1/3 10-HOLE/121MM 241.40
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$96.10 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$96.10
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Devoted Health Medicare |
$105.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$96.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.10
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.10
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
PLATE 1/3 10-HOLE/121MM 241.40
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
PLATE 1/3 2-HOLE/25MM 241.32
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$118.11 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: AlohaCare Medicaid |
$190.50
|
| Rate for Payer: AlohaCare Medicare |
$118.11
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Devoted Health Medicare |
$129.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.70
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Humana Medicare |
$118.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.11
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.11
|
| Rate for Payer: University Health Alliance Commercial |
$213.36
|
|
|
PLATE 1/3 2-HOLE/25MM 241.32
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$213.36 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.70
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: University Health Alliance Commercial |
$213.36
|
|
|
PLATE 1/3 3-HOLE/37MM 241.33
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$217.84 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$272.30
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
| Rate for Payer: University Health Alliance Commercial |
$217.84
|
|
|
PLATE 1/3 3-HOLE/37MM 241.33
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$120.59 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: AlohaCare Medicaid |
$194.50
|
| Rate for Payer: AlohaCare Medicare |
$120.59
|
| Rate for Payer: Cash Price |
$233.40
|
| Rate for Payer: Devoted Health Medicare |
$132.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$272.30
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Humana Medicare |
$120.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$120.59
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.59
|
| Rate for Payer: University Health Alliance Commercial |
$217.84
|
|
|
PLATE 1/3 8-HOLE/97MM 241.38
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$252.00 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$315.00
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: University Health Alliance Commercial |
$252.00
|
|
|
PLATE 1/3 8-HOLE/97MM 241.38
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$139.50 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Devoted Health Medicare |
$153.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$315.00
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| Rate for Payer: University Health Alliance Commercial |
$252.00
|
|
|
PLATE 1/3 9-HOLE/109MM 241.39
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$168.33 |
| Max. Negotiated Rate |
$526.71 |
| Rate for Payer: AlohaCare Medicaid |
$271.50
|
| Rate for Payer: AlohaCare Medicare |
$168.33
|
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Devoted Health Medicare |
$184.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$168.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$380.10
|
| Rate for Payer: Health Management Network Commercial |
$461.55
|
| Rate for Payer: Humana Medicare |
$168.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$488.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$276.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$168.33
|
| Rate for Payer: MDX Hawaii PPO |
$526.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$168.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$168.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$168.33
|
| Rate for Payer: University Health Alliance Commercial |
$304.08
|
|
|
PLATE 1/3 9-HOLE/109MM 241.39
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$304.08 |
| Max. Negotiated Rate |
$526.71 |
| Rate for Payer: Cash Price |
$325.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$380.10
|
| Rate for Payer: Health Management Network Commercial |
$461.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$488.70
|
| Rate for Payer: MDX Hawaii PPO |
$526.71
|
| Rate for Payer: University Health Alliance Commercial |
$304.08
|
|
|
PLATE 1/3 TUBULAR 10H 626680
|
Facility
|
OP
|
$1,848.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$572.88 |
| Max. Negotiated Rate |
$1,792.56 |
| Rate for Payer: AlohaCare Medicaid |
$924.00
|
| Rate for Payer: AlohaCare Medicare |
$572.88
|
| Rate for Payer: Cash Price |
$1,108.80
|
| Rate for Payer: Devoted Health Medicare |
$628.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$572.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,293.60
|
| Rate for Payer: Health Management Network Commercial |
$1,570.80
|
| Rate for Payer: Humana Medicare |
$572.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,663.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$942.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$572.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,792.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$572.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$572.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$572.88
|
| Rate for Payer: University Health Alliance Commercial |
$1,034.88
|
|
|
PLATE 1/3 TUBULAR 10H 626680
|
Facility
|
IP
|
$1,848.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,034.88 |
| Max. Negotiated Rate |
$1,792.56 |
| Rate for Payer: Cash Price |
$1,108.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,293.60
|
| Rate for Payer: Health Management Network Commercial |
$1,570.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,663.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,792.56
|
| Rate for Payer: University Health Alliance Commercial |
$1,034.88
|
|
|
PLATE 1/3 TUBULAR 83 7H 626677
|
Facility
|
IP
|
$1,608.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$900.48 |
| Max. Negotiated Rate |
$1,559.76 |
| Rate for Payer: Cash Price |
$964.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,125.60
|
| Rate for Payer: Health Management Network Commercial |
$1,366.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,447.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,559.76
|
| Rate for Payer: University Health Alliance Commercial |
$900.48
|
|
