|
BLADE TI SPIRAL 54MM
|
Facility
|
OP
|
$2,748.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$851.88 |
| Max. Negotiated Rate |
$2,665.56 |
| Rate for Payer: AlohaCare Medicaid |
$1,374.00
|
| Rate for Payer: AlohaCare Medicare |
$851.88
|
| Rate for Payer: Cash Price |
$1,648.80
|
| Rate for Payer: Devoted Health Medicare |
$934.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$851.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,923.60
|
| Rate for Payer: Health Management Network Commercial |
$2,335.80
|
| Rate for Payer: Humana Medicare |
$851.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,473.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,401.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$851.88
|
| Rate for Payer: MDX Hawaii PPO |
$2,665.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$851.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$851.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$851.88
|
| Rate for Payer: University Health Alliance Commercial |
$1,538.88
|
|
|
BLADE TI SPIRAL 54MM
|
Facility
|
IP
|
$2,748.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,538.88 |
| Max. Negotiated Rate |
$2,665.56 |
| Rate for Payer: Cash Price |
$1,648.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,923.60
|
| Rate for Payer: Health Management Network Commercial |
$2,335.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,473.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,665.56
|
| Rate for Payer: University Health Alliance Commercial |
$1,538.88
|
|
|
BLADE TI SPIRAL INSRTR 358.696
|
Facility
|
IP
|
$2,316.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,968.60 |
| Max. Negotiated Rate |
$2,246.52 |
| Rate for Payer: Cash Price |
$1,389.60
|
| Rate for Payer: Health Management Network Commercial |
$1,968.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,084.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,246.52
|
|
|
BLADE TI SPIRAL INSRTR 358.696
|
Facility
|
OP
|
$2,316.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$717.96 |
| Max. Negotiated Rate |
$2,246.52 |
| Rate for Payer: AlohaCare Medicaid |
$1,158.00
|
| Rate for Payer: AlohaCare Medicare |
$717.96
|
| Rate for Payer: Cash Price |
$1,389.60
|
| Rate for Payer: Devoted Health Medicare |
$787.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$717.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,200.20
|
| Rate for Payer: Health Management Network Commercial |
$1,968.60
|
| Rate for Payer: Humana Medicare |
$717.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,084.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,181.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$717.96
|
| Rate for Payer: MDX Hawaii PPO |
$2,246.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$717.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$717.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$717.96
|
| Rate for Payer: University Health Alliance Commercial |
$1,688.13
|
|
|
BLADE TYMPANOPLASTY 2.5MM
|
Facility
|
OP
|
$460.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: AlohaCare Medicaid |
$230.00
|
| Rate for Payer: AlohaCare Medicare |
$142.60
|
| Rate for Payer: Cash Price |
$276.00
|
| Rate for Payer: Devoted Health Medicare |
$156.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$142.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$437.00
|
| Rate for Payer: Health Management Network Commercial |
$391.00
|
| Rate for Payer: Humana Medicare |
$142.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$414.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$234.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$142.60
|
| Rate for Payer: MDX Hawaii PPO |
$446.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$142.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$142.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$142.60
|
| Rate for Payer: University Health Alliance Commercial |
$335.29
|
|
|
BLADE TYMPANOPLASTY 2.5MM
|
Facility
|
IP
|
$460.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$391.00 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: Cash Price |
$276.00
|
| Rate for Payer: Health Management Network Commercial |
$391.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$414.00
|
| Rate for Payer: MDX Hawaii PPO |
$446.20
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J9040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION [9289]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J9040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicaid |
$61.00
|
| Rate for Payer: AlohaCare Medicaid |
$46.50
|
| Rate for Payer: AlohaCare Medicare |
$28.83
|
| Rate for Payer: AlohaCare Medicare |
$37.82
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Devoted Health Medicare |
$31.62
|
| Rate for Payer: Devoted Health Medicare |
$41.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$115.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Humana Medicare |
$37.82
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Humana Medicare |
$28.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$88.93
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
| Rate for Payer: University Health Alliance Commercial |
$67.79
|
|
|
BLN ENROUTE ENFLATE SR-4025-BC
|
Facility
|
OP
|
$1,496.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$463.76 |
| Max. Negotiated Rate |
$1,451.12 |
| Rate for Payer: AlohaCare Medicaid |
$748.00
|
| Rate for Payer: AlohaCare Medicare |
$463.76
|
| Rate for Payer: Cash Price |
$897.60
|
| Rate for Payer: Devoted Health Medicare |
$508.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$463.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,421.20
|
| Rate for Payer: Health Management Network Commercial |
$1,271.60
|
| Rate for Payer: Humana Medicare |
$463.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,346.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$762.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$463.76
|
| Rate for Payer: MDX Hawaii PPO |
$1,451.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$463.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$463.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$463.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,090.43
|
|
|
BLN ENROUTE ENFLATE SR-4025-BC
|
Facility
|
IP
|
$1,496.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,271.60 |
| Max. Negotiated Rate |
$1,451.12 |
| Rate for Payer: Cash Price |
$897.60
|
| Rate for Payer: Health Management Network Commercial |
$1,271.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,346.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,451.12
|
|
|
BONE ANCHOR ADVANCE SYS 4403
|
Facility
|
OP
|
$2,200.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$682.00 |
| Max. Negotiated Rate |
$2,134.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,100.00
|
| Rate for Payer: AlohaCare Medicare |
$682.00
|
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Devoted Health Medicare |
$748.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$682.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,540.00
|
| Rate for Payer: Health Management Network Commercial |
$1,870.00
|
| Rate for Payer: Humana Medicare |
$682.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,980.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,122.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$682.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,134.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$682.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$682.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$682.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,232.00
|
|
|
BONE ANCHOR ADVANCE SYS 4403
|
Facility
|
IP
|
$2,200.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,232.00 |
| Max. Negotiated Rate |
$2,134.00 |
| Rate for Payer: Cash Price |
$1,320.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,540.00
|
| Rate for Payer: Health Management Network Commercial |
$1,870.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,980.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,134.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,232.00
|
|
|
BONE CEMENT 110043026
|
Facility
|
OP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.15 |
| Max. Negotiated Rate |
$1,033.05 |
| Rate for Payer: AlohaCare Medicaid |
$532.50
|
| Rate for Payer: AlohaCare Medicare |
$330.15
|
| Rate for Payer: Cash Price |
$639.00
|
| Rate for Payer: Devoted Health Medicare |
$362.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$330.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$745.50
|
| Rate for Payer: Health Management Network Commercial |
$905.25
|
| Rate for Payer: Humana Medicare |
$330.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$958.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$543.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$330.15
|
| Rate for Payer: MDX Hawaii PPO |
$1,033.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$330.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$330.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$330.15
|
| Rate for Payer: University Health Alliance Commercial |
$596.40
|
|
|
BONE CEMENT 110043026
|
Facility
|
IP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$596.40 |
| Max. Negotiated Rate |
$1,033.05 |
| Rate for Payer: Cash Price |
$639.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$745.50
|
| Rate for Payer: Health Management Network Commercial |
$905.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$958.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,033.05
|
| Rate for Payer: University Health Alliance Commercial |
$596.40
|
|
|
BONE CEMENT FEMORAL PREP KIT
|
Facility
|
IP
|
$1,085.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.60 |
| Max. Negotiated Rate |
$1,052.45 |
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$759.50
|
| Rate for Payer: Health Management Network Commercial |
$922.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$976.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,052.45
|
| Rate for Payer: University Health Alliance Commercial |
$607.60
|
|
|
BONE CEMENT FEMORAL PREP KIT
|
Facility
|
OP
|
$1,085.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$336.35 |
| Max. Negotiated Rate |
$1,052.45 |
| Rate for Payer: AlohaCare Medicaid |
$542.50
|
| Rate for Payer: AlohaCare Medicare |
$336.35
|
| Rate for Payer: Cash Price |
$651.00
|
| Rate for Payer: Devoted Health Medicare |
$368.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$336.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$759.50
|
| Rate for Payer: Health Management Network Commercial |
$922.25
|
| Rate for Payer: Humana Medicare |
$336.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$976.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$553.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$336.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,052.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$336.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$336.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$336.35
|
| Rate for Payer: University Health Alliance Commercial |
$607.60
|
|
|
BONE CEMENT R 1X40 110034355
|
Facility
|
IP
|
$1,033.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$578.48 |
| Max. Negotiated Rate |
$1,002.01 |
| Rate for Payer: Cash Price |
$619.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$723.10
|
| Rate for Payer: Health Management Network Commercial |
$878.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$929.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,002.01
|
| Rate for Payer: University Health Alliance Commercial |
$578.48
|
|
|
BONE CEMENT R 1X40 110034355
|
Facility
|
OP
|
$1,033.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$320.23 |
| Max. Negotiated Rate |
$1,002.01 |
| Rate for Payer: AlohaCare Medicaid |
$516.50
|
| Rate for Payer: AlohaCare Medicare |
$320.23
|
| Rate for Payer: Cash Price |
$619.80
|
| Rate for Payer: Devoted Health Medicare |
$351.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$320.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$723.10
|
| Rate for Payer: Health Management Network Commercial |
$878.05
|
| Rate for Payer: Humana Medicare |
$320.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$929.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$526.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$320.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,002.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$320.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$320.23
|
| Rate for Payer: University Health Alliance Commercial |
$578.48
|
|
|
BONE CUTTER AR-8400BC
|
Facility
|
OP
|
$232.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.92 |
| Max. Negotiated Rate |
$225.04 |
| Rate for Payer: AlohaCare Medicaid |
$116.00
|
| Rate for Payer: AlohaCare Medicare |
$71.92
|
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Devoted Health Medicare |
$78.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$220.40
|
| Rate for Payer: Health Management Network Commercial |
$197.20
|
| Rate for Payer: Humana Medicare |
$71.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$208.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$118.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.92
|
| Rate for Payer: MDX Hawaii PPO |
$225.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.92
|
| Rate for Payer: University Health Alliance Commercial |
$169.10
|
|
|
BONE CUTTER AR-8400BC
|
Facility
|
IP
|
$232.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.20 |
| Max. Negotiated Rate |
$225.04 |
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Health Management Network Commercial |
$197.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$208.80
|
| Rate for Payer: MDX Hawaii PPO |
$225.04
|
|
|
BONE DISEASES AND ARTHROPATHIES WITH MCC
|
Facility
|
IP
|
$12,490.95
|
|
|
Service Code
|
MSDRG 553
|
| Min. Negotiated Rate |
$12,490.95 |
| Max. Negotiated Rate |
$12,490.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,490.95
|
|
|
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC
|
Facility
|
IP
|
$12,396.15
|
|
|
Service Code
|
MSDRG 554
|
| Min. Negotiated Rate |
$12,396.15 |
| Max. Negotiated Rate |
$12,396.15 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,396.15
|
|
|
BONE FILLER 10CC KIT OB-10P
|
Facility
|
IP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.00 |
| Max. Negotiated Rate |
$5,529.00 |
| Rate for Payer: Cash Price |
$3,420.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,990.00
|
| Rate for Payer: Health Management Network Commercial |
$4,845.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,130.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,529.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,192.00
|
|
|
BONE FILLER 10CC KIT OB-10P
|
Facility
|
OP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,767.00 |
| Max. Negotiated Rate |
$5,529.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,850.00
|
| Rate for Payer: AlohaCare Medicare |
$1,767.00
|
| Rate for Payer: Cash Price |
$3,420.00
|
| Rate for Payer: Devoted Health Medicare |
$1,938.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,767.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,990.00
|
| Rate for Payer: Health Management Network Commercial |
$4,845.00
|
| Rate for Payer: Humana Medicare |
$1,767.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,130.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,907.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,767.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,529.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,767.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,767.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,767.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,192.00
|
|
|
BONE GRAFT FILLER 07.704.003S
|
Facility
|
IP
|
$2,944.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,648.64 |
| Max. Negotiated Rate |
$2,855.68 |
| Rate for Payer: Cash Price |
$1,766.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,060.80
|
| Rate for Payer: Health Management Network Commercial |
$2,502.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,649.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,855.68
|
| Rate for Payer: University Health Alliance Commercial |
$1,648.64
|
|
