|
PLATE LCP 3.5/8H/RT 02.112.020
|
Facility
|
IP
|
$3,160.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.60 |
| Max. Negotiated Rate |
$3,065.20 |
| Rate for Payer: Cash Price |
$1,896.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,212.00
|
| Rate for Payer: Health Management Network Commercial |
$2,686.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,844.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,065.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,769.60
|
|
|
PLATE LCP 3.5/8H/RT 02.112.030
|
Facility
|
IP
|
$2,277.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.12 |
| Max. Negotiated Rate |
$2,208.69 |
| Rate for Payer: Cash Price |
$1,366.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,593.90
|
| Rate for Payer: Health Management Network Commercial |
$1,935.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,049.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,208.69
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.12
|
|
|
PLATE LCP 3.5/8H/RT 02.112.030
|
Facility
|
OP
|
$2,277.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$705.87 |
| Max. Negotiated Rate |
$2,208.69 |
| Rate for Payer: AlohaCare Medicaid |
$1,138.50
|
| Rate for Payer: AlohaCare Medicare |
$705.87
|
| Rate for Payer: Cash Price |
$1,366.20
|
| Rate for Payer: Devoted Health Medicare |
$774.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$705.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,593.90
|
| Rate for Payer: Health Management Network Commercial |
$1,935.45
|
| Rate for Payer: Humana Medicare |
$705.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,049.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,161.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$705.87
|
| Rate for Payer: MDX Hawaii PPO |
$2,208.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$705.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$705.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$705.87
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.12
|
|
|
PLATE LCP 3.5/8H/RT 02.112.084
|
Facility
|
OP
|
$3,160.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.60 |
| Max. Negotiated Rate |
$3,065.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,580.00
|
| Rate for Payer: AlohaCare Medicare |
$979.60
|
| Rate for Payer: Cash Price |
$1,896.00
|
| Rate for Payer: Devoted Health Medicare |
$1,074.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$979.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,212.00
|
| Rate for Payer: Health Management Network Commercial |
$2,686.00
|
| Rate for Payer: Humana Medicare |
$979.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,844.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,611.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$979.60
|
| Rate for Payer: MDX Hawaii PPO |
$3,065.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$979.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$979.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$979.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,769.60
|
|
|
PLATE LCP 3.5/8H/RT 02.112.084
|
Facility
|
IP
|
$3,160.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,769.60 |
| Max. Negotiated Rate |
$3,065.20 |
| Rate for Payer: Cash Price |
$1,896.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,212.00
|
| Rate for Payer: Health Management Network Commercial |
$2,686.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,844.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,065.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,769.60
|
|
|
PLATE LCP 3.5/8H/RT 02.127.230
|
Facility
|
IP
|
$4,215.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,360.40 |
| Max. Negotiated Rate |
$4,088.55 |
| Rate for Payer: Cash Price |
$2,529.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,950.50
|
| Rate for Payer: Health Management Network Commercial |
$3,582.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,793.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,088.55
|
| Rate for Payer: University Health Alliance Commercial |
$2,360.40
|
|
|
PLATE LCP 3.5/8H/RT 02.127.230
|
Facility
|
OP
|
$4,215.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,306.65 |
| Max. Negotiated Rate |
$4,088.55 |
| Rate for Payer: AlohaCare Medicaid |
$2,107.50
|
| Rate for Payer: AlohaCare Medicare |
$1,306.65
|
| Rate for Payer: Cash Price |
$2,529.00
|
| Rate for Payer: Devoted Health Medicare |
$1,433.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,306.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,950.50
|
| Rate for Payer: Health Management Network Commercial |
$3,582.75
|
| Rate for Payer: Humana Medicare |
$1,306.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,793.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,149.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,306.65
|
| Rate for Payer: MDX Hawaii PPO |
$4,088.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,306.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,306.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,306.65
|
| Rate for Payer: University Health Alliance Commercial |
$2,360.40
|
|
|
PLATE LCP 3.5 CLAVICLE HOOK
|
Facility
|
OP
|
$2,774.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.94 |
| Max. Negotiated Rate |
$2,690.78 |
| Rate for Payer: AlohaCare Medicaid |
$1,387.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,331.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,497.50
|
| Rate for Payer: AlohaCare Medicaid |
$1,294.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,237.00
|
| Rate for Payer: AlohaCare Medicare |
$766.94
|
| Rate for Payer: AlohaCare Medicare |
$825.22
|
| Rate for Payer: AlohaCare Medicare |
$859.94
|
| Rate for Payer: AlohaCare Medicare |
$928.45
|
| Rate for Payer: AlohaCare Medicare |
$802.28
|
| Rate for Payer: Cash Price |
$1,664.40
|
| Rate for Payer: Cash Price |
$1,597.20
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,484.40
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Devoted Health Medicare |
$905.08
|
| Rate for Payer: Devoted Health Medicare |
$879.92
|
| Rate for Payer: Devoted Health Medicare |
$1,018.30
|
| Rate for Payer: Devoted Health Medicare |
$943.16
|
| Rate for Payer: Devoted Health Medicare |
$841.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$766.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$928.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$802.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$859.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$825.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,096.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,731.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,811.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,863.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,941.80
|
| Rate for Payer: Health Management Network Commercial |
$2,357.90
|
| Rate for Payer: Health Management Network Commercial |
$2,102.90
|
| Rate for Payer: Health Management Network Commercial |
$2,262.70
|
| Rate for Payer: Health Management Network Commercial |
$2,199.80
|
| Rate for Payer: Health Management Network Commercial |
$2,545.75
|
| Rate for Payer: Humana Medicare |
$766.94
|
| Rate for Payer: Humana Medicare |
$802.28
|
| Rate for Payer: Humana Medicare |
$825.22
|
| Rate for Payer: Humana Medicare |
$859.94
|
| Rate for Payer: Humana Medicare |
$928.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,329.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,695.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,226.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,395.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,496.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,261.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,319.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,357.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,414.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,527.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$766.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$859.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$802.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$928.45
|
| Rate for Payer: MDX Hawaii PPO |
$2,399.78
|
| Rate for Payer: MDX Hawaii PPO |
$2,582.14
|
| Rate for Payer: MDX Hawaii PPO |
$2,510.36
|
| Rate for Payer: MDX Hawaii PPO |
$2,905.15
|
| Rate for Payer: MDX Hawaii PPO |
$2,690.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$766.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$859.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$928.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$802.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$859.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$928.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$802.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$766.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$802.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$928.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$766.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$859.94
|
| Rate for Payer: University Health Alliance Commercial |
$1,553.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,490.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,677.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,385.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,449.28
|
|
|
PLATE LCP 3.5 CLAVICLE HOOK
|
Facility
|
IP
|
$2,662.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,490.72 |
| Max. Negotiated Rate |
$2,582.14 |
| Rate for Payer: Cash Price |
$1,597.20
|
| Rate for Payer: Cash Price |
$1,552.80
|
| Rate for Payer: Cash Price |
$1,484.40
|
| Rate for Payer: Cash Price |
$1,664.40
|
| Rate for Payer: Cash Price |
$1,797.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,941.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,731.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,811.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,863.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,096.50
|
| Rate for Payer: Health Management Network Commercial |
$2,357.90
|
| Rate for Payer: Health Management Network Commercial |
$2,545.75
|
| Rate for Payer: Health Management Network Commercial |
$2,102.90
|
| Rate for Payer: Health Management Network Commercial |
$2,199.80
|
| Rate for Payer: Health Management Network Commercial |
$2,262.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,329.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,226.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,395.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,496.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,695.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,510.36
|
| Rate for Payer: MDX Hawaii PPO |
$2,399.78
|
| Rate for Payer: MDX Hawaii PPO |
$2,582.14
|
| Rate for Payer: MDX Hawaii PPO |
$2,690.78
|
| Rate for Payer: MDX Hawaii PPO |
$2,905.15
|
| Rate for Payer: University Health Alliance Commercial |
$1,490.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,449.28
|
| Rate for Payer: University Health Alliance Commercial |
$1,385.44
|
| Rate for Payer: University Health Alliance Commercial |
$1,677.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,553.44
|
|
|
PLATE LCP 3.5M 02.112.042
|
Facility
|
OP
|
$2,277.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$705.87 |
| Max. Negotiated Rate |
$2,208.69 |
| Rate for Payer: AlohaCare Medicaid |
$1,138.50
|
| Rate for Payer: AlohaCare Medicare |
$705.87
|
| Rate for Payer: Cash Price |
$1,366.20
|
| Rate for Payer: Devoted Health Medicare |
$774.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$705.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,593.90
|
| Rate for Payer: Health Management Network Commercial |
$1,935.45
|
| Rate for Payer: Humana Medicare |
$705.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,049.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,161.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$705.87
|
| Rate for Payer: MDX Hawaii PPO |
$2,208.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$705.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$705.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$705.87
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.12
|
|
|
PLATE LCP 3.5M 02.112.042
|
Facility
|
IP
|
$2,277.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.12 |
| Max. Negotiated Rate |
$2,208.69 |
| Rate for Payer: Cash Price |
$1,366.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,593.90
|
| Rate for Payer: Health Management Network Commercial |
$1,935.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,049.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,208.69
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.12
|
|
|
PLATE LCP 3.5X86MM RT 236.502
|
Facility
|
IP
|
$2,073.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,160.88 |
| Max. Negotiated Rate |
$2,010.81 |
| Rate for Payer: Cash Price |
$1,243.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,451.10
|
| Rate for Payer: Health Management Network Commercial |
$1,762.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,865.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,010.81
|
| Rate for Payer: University Health Alliance Commercial |
$1,160.88
|
|
|
PLATE LCP 3.5X86MM RT 236.502
|
Facility
|
OP
|
$2,073.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.63 |
| Max. Negotiated Rate |
$2,010.81 |
| Rate for Payer: AlohaCare Medicaid |
$1,036.50
|
| Rate for Payer: AlohaCare Medicare |
$642.63
|
| Rate for Payer: Cash Price |
$1,243.80
|
| Rate for Payer: Devoted Health Medicare |
$704.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$642.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,451.10
|
| Rate for Payer: Health Management Network Commercial |
$1,762.05
|
| Rate for Payer: Humana Medicare |
$642.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,865.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,057.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$642.63
|
| Rate for Payer: MDX Hawaii PPO |
$2,010.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$642.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$642.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$642.63
|
| Rate for Payer: University Health Alliance Commercial |
$1,160.88
|
|
|
PLATE LCP 3H 3.5X90MM 241.901
|
Facility
|
OP
|
$3,409.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,056.79 |
| Max. Negotiated Rate |
$3,306.73 |
| Rate for Payer: AlohaCare Medicaid |
$1,704.50
|
| Rate for Payer: AlohaCare Medicare |
$1,056.79
|
| Rate for Payer: Cash Price |
$2,045.40
|
| Rate for Payer: Devoted Health Medicare |
$1,159.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,056.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,386.30
|
| Rate for Payer: Health Management Network Commercial |
$2,897.65
|
| Rate for Payer: Humana Medicare |
$1,056.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,068.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,738.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,056.79
|
| Rate for Payer: MDX Hawaii PPO |
$3,306.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,056.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,056.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,056.79
|
| Rate for Payer: University Health Alliance Commercial |
$1,909.04
|
|
|
PLATE LCP 3H 3.5X90MM 241.901
|
Facility
|
IP
|
$3,409.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,909.04 |
| Max. Negotiated Rate |
$3,306.73 |
| Rate for Payer: Cash Price |
$2,045.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,386.30
|
| Rate for Payer: Health Management Network Commercial |
$2,897.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,068.10
|
| Rate for Payer: MDX Hawaii PPO |
$3,306.73
|
| Rate for Payer: University Health Alliance Commercial |
$1,909.04
|
|
|
PLATE LCP 3H 4.5X62MM 224.531
|
Facility
|
OP
|
$1,694.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$525.14 |
| Max. Negotiated Rate |
$1,643.18 |
| Rate for Payer: AlohaCare Medicaid |
$847.00
|
| Rate for Payer: AlohaCare Medicare |
$525.14
|
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Devoted Health Medicare |
$575.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$525.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,185.80
|
| Rate for Payer: Health Management Network Commercial |
$1,439.90
|
| Rate for Payer: Humana Medicare |
$525.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,524.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$863.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$525.14
|
| Rate for Payer: MDX Hawaii PPO |
$1,643.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$525.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$525.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$525.14
|
| Rate for Payer: University Health Alliance Commercial |
$948.64
|
|
|
PLATE LCP 3H 4.5X62MM 224.531
|
Facility
|
IP
|
$1,694.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.64 |
| Max. Negotiated Rate |
$1,643.18 |
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,185.80
|
| Rate for Payer: Health Management Network Commercial |
$1,439.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,524.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,643.18
|
| Rate for Payer: University Health Alliance Commercial |
$948.64
|
|
|
PLATE LCP 4.5X266MM 02.124.413
|
Facility
|
OP
|
$4,419.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,369.89 |
| Max. Negotiated Rate |
$4,286.43 |
| Rate for Payer: AlohaCare Medicaid |
$2,209.50
|
| Rate for Payer: AlohaCare Medicare |
$1,369.89
|
| Rate for Payer: Cash Price |
$2,651.40
|
| Rate for Payer: Devoted Health Medicare |
$1,502.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,369.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,093.30
|
| Rate for Payer: Health Management Network Commercial |
$3,756.15
|
| Rate for Payer: Humana Medicare |
$1,369.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,977.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,253.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,369.89
|
| Rate for Payer: MDX Hawaii PPO |
$4,286.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,369.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,369.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,369.89
|
| Rate for Payer: University Health Alliance Commercial |
$2,474.64
|
|
|
PLATE LCP 4.5X266MM 02.124.413
|
Facility
|
IP
|
$4,419.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,474.64 |
| Max. Negotiated Rate |
$4,286.43 |
| Rate for Payer: Cash Price |
$2,651.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,093.30
|
| Rate for Payer: Health Management Network Commercial |
$3,756.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,977.10
|
| Rate for Payer: MDX Hawaii PPO |
$4,286.43
|
| Rate for Payer: University Health Alliance Commercial |
$2,474.64
|
|
|
PLATE LCP 4.5X3.5 12H 224.757
|
Facility
|
IP
|
$2,923.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,636.88 |
| Max. Negotiated Rate |
$2,835.31 |
| Rate for Payer: Cash Price |
$1,753.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,046.10
|
| Rate for Payer: Health Management Network Commercial |
$2,484.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,630.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,835.31
|
| Rate for Payer: University Health Alliance Commercial |
$1,636.88
|
|
|
PLATE LCP 4.5X3.5 12H 224.757
|
Facility
|
OP
|
$2,923.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$906.13 |
| Max. Negotiated Rate |
$2,835.31 |
| Rate for Payer: AlohaCare Medicaid |
$1,461.50
|
| Rate for Payer: AlohaCare Medicare |
$906.13
|
| Rate for Payer: Cash Price |
$1,753.80
|
| Rate for Payer: Devoted Health Medicare |
$993.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$906.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,046.10
|
| Rate for Payer: Health Management Network Commercial |
$2,484.55
|
| Rate for Payer: Humana Medicare |
$906.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,630.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,490.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$906.13
|
| Rate for Payer: MDX Hawaii PPO |
$2,835.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$906.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$906.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$906.13
|
| Rate for Payer: University Health Alliance Commercial |
$1,636.88
|
|
|
PLATE LCP 4H 109MM 04.112.510
|
Facility
|
IP
|
$3,542.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,983.52 |
| Max. Negotiated Rate |
$3,435.74 |
| Rate for Payer: Cash Price |
$2,125.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,479.40
|
| Rate for Payer: Health Management Network Commercial |
$3,010.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,187.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,435.74
|
| Rate for Payer: University Health Alliance Commercial |
$1,983.52
|
|
|
PLATE LCP 4H 109MM 04.112.510
|
Facility
|
OP
|
$3,542.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,098.02 |
| Max. Negotiated Rate |
$3,435.74 |
| Rate for Payer: AlohaCare Medicaid |
$1,771.00
|
| Rate for Payer: AlohaCare Medicare |
$1,098.02
|
| Rate for Payer: Cash Price |
$2,125.20
|
| Rate for Payer: Devoted Health Medicare |
$1,204.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,098.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,479.40
|
| Rate for Payer: Health Management Network Commercial |
$3,010.70
|
| Rate for Payer: Humana Medicare |
$1,098.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,187.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,806.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,098.02
|
| Rate for Payer: MDX Hawaii PPO |
$3,435.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,098.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,098.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,098.02
|
| Rate for Payer: University Health Alliance Commercial |
$1,983.52
|
|
|
PLATE LCP 4H 3.5X81MM #239.934
|
Facility
|
IP
|
$4,472.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,504.32 |
| Max. Negotiated Rate |
$4,337.84 |
| Rate for Payer: Cash Price |
$2,683.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,130.40
|
| Rate for Payer: Health Management Network Commercial |
$3,801.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,024.80
|
| Rate for Payer: MDX Hawaii PPO |
$4,337.84
|
| Rate for Payer: University Health Alliance Commercial |
$2,504.32
|
|
|
PLATE LCP 4H 3.5X81MM #239.934
|
Facility
|
OP
|
$4,472.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.32 |
| Max. Negotiated Rate |
$4,337.84 |
| Rate for Payer: AlohaCare Medicaid |
$2,236.00
|
| Rate for Payer: AlohaCare Medicare |
$1,386.32
|
| Rate for Payer: Cash Price |
$2,683.20
|
| Rate for Payer: Devoted Health Medicare |
$1,520.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,386.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,130.40
|
| Rate for Payer: Health Management Network Commercial |
$3,801.20
|
| Rate for Payer: Humana Medicare |
$1,386.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,024.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,280.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,386.32
|
| Rate for Payer: MDX Hawaii PPO |
$4,337.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,386.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,386.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,386.32
|
| Rate for Payer: University Health Alliance Commercial |
$2,504.32
|
|
