|
BREAST HSC+ 10721-215MP
|
Facility
|
OP
|
$2,850.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$883.50 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,425.00
|
| Rate for Payer: AlohaCare Medicare |
$883.50
|
| Rate for Payer: Cash Price |
$1,710.00
|
| Rate for Payer: Devoted Health Medicare |
$969.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$883.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,995.00
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Humana Medicare |
$883.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,453.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$883.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$883.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$883.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$883.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,596.00
|
|
|
BREAST IMPLANT SZ10621-305MP
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$169.75 |
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.50
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.50
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: University Health Alliance Commercial |
$98.00
|
|
|
BREAST IMPLANT SZ10621-305MP
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$54.25 |
| Max. Negotiated Rate |
$169.75 |
| Rate for Payer: AlohaCare Medicaid |
$87.50
|
| Rate for Payer: AlohaCare Medicare |
$54.25
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Devoted Health Medicare |
$59.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.50
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Humana Medicare |
$54.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.25
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.25
|
| Rate for Payer: University Health Alliance Commercial |
$98.00
|
|
|
BREAST SILICONE GS10610-190LP
|
Facility
|
IP
|
$844.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$472.64 |
| Max. Negotiated Rate |
$818.68 |
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$590.80
|
| Rate for Payer: Health Management Network Commercial |
$717.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$759.60
|
| Rate for Payer: MDX Hawaii PPO |
$818.68
|
| Rate for Payer: University Health Alliance Commercial |
$472.64
|
|
|
BREAST SILICONE GS10610-190LP
|
Facility
|
OP
|
$844.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$261.64 |
| Max. Negotiated Rate |
$818.68 |
| Rate for Payer: AlohaCare Medicaid |
$422.00
|
| Rate for Payer: AlohaCare Medicare |
$261.64
|
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Devoted Health Medicare |
$286.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$261.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$590.80
|
| Rate for Payer: Health Management Network Commercial |
$717.40
|
| Rate for Payer: Humana Medicare |
$261.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$759.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$430.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$261.64
|
| Rate for Payer: MDX Hawaii PPO |
$818.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$261.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$261.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$261.64
|
| Rate for Payer: University Health Alliance Commercial |
$472.64
|
|
|
BREAST TISSUE ALLOX2-FH14SE
|
Facility
|
OP
|
$3,750.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,637.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,875.00
|
| Rate for Payer: AlohaCare Medicare |
$1,162.50
|
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Devoted Health Medicare |
$1,275.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,162.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,625.00
|
| Rate for Payer: Health Management Network Commercial |
$3,187.50
|
| Rate for Payer: Humana Medicare |
$1,162.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,375.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,912.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,162.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,637.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,162.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,162.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,162.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,100.00
|
|
|
BREAST TISSUE ALLOX2-FH14SE
|
Facility
|
IP
|
$3,750.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,100.00 |
| Max. Negotiated Rate |
$3,637.50 |
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,625.00
|
| Rate for Payer: Health Management Network Commercial |
$3,187.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,375.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,637.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,100.00
|
|
|
BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]
|
Facility
|
OP
|
$15,711.00
|
|
|
Service Code
|
HCPCS J9042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.52 |
| Max. Negotiated Rate |
$15,239.67 |
| Rate for Payer: AlohaCare Medicaid |
$7,855.50
|
| Rate for Payer: AlohaCare Medicare |
$4,870.41
|
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Devoted Health Medicare |
$5,341.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$258.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$335.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,870.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$258.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,925.45
|
| Rate for Payer: Health Management Network Commercial |
$13,354.35
|
| Rate for Payer: Humana Medicare |
$4,870.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,139.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,012.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,870.41
|
| Rate for Payer: MDX Hawaii PPO |
$15,239.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,870.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,870.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,426.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,870.41
|
| Rate for Payer: University Health Alliance Commercial |
$11,451.75
|
|
|
BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]
|
Facility
|
IP
|
$15,711.00
|
|
|
Service Code
|
HCPCS J9042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,354.35 |
| Max. Negotiated Rate |
$15,239.67 |
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Health Management Network Commercial |
$13,354.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,139.90
|
| Rate for Payer: MDX Hawaii PPO |
$15,239.67
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]
|
Facility
|
OP
|
$15,711.00
|
|
|
Service Code
|
HCPCS J9042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$258.52 |
| Max. Negotiated Rate |
$15,239.67 |
| Rate for Payer: AlohaCare Medicaid |
$7,855.50
|
| Rate for Payer: AlohaCare Medicaid |
$8,099.00
|
| Rate for Payer: AlohaCare Medicare |
$5,021.38
|
| Rate for Payer: AlohaCare Medicare |
$4,870.41
|
| Rate for Payer: Cash Price |
$9,718.80
|
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Cash Price |
$9,718.80
|
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Devoted Health Medicare |
$5,341.74
|
| Rate for Payer: Devoted Health Medicare |
$5,507.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$258.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$258.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$335.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$335.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,021.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,870.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$258.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$258.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,925.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,388.10
|
| Rate for Payer: Health Management Network Commercial |
$13,768.30
|
| Rate for Payer: Health Management Network Commercial |
$13,354.35
|
| Rate for Payer: Humana Medicare |
$4,870.41
|
| Rate for Payer: Humana Medicare |
$5,021.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,139.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,578.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,260.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,012.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,870.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,021.38
|
| Rate for Payer: MDX Hawaii PPO |
$15,239.67
|
| Rate for Payer: MDX Hawaii PPO |
$15,712.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,021.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,870.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,870.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,021.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,718.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,426.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,870.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,021.38
|
| Rate for Payer: University Health Alliance Commercial |
$11,451.75
|
| Rate for Payer: University Health Alliance Commercial |
$11,806.72
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]
|
Facility
|
IP
|
$15,711.00
|
|
|
Service Code
|
HCPCS J9042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,354.35 |
| Max. Negotiated Rate |
$15,239.67 |
| Rate for Payer: Cash Price |
$9,426.60
|
| Rate for Payer: Cash Price |
$9,718.80
|
| Rate for Payer: Health Management Network Commercial |
$13,354.35
|
| Rate for Payer: Health Management Network Commercial |
$13,768.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,139.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,578.20
|
| Rate for Payer: MDX Hawaii PPO |
$15,712.06
|
| Rate for Payer: MDX Hawaii PPO |
$15,239.67
|
|
|
BRIDGE PLATE BRGP
|
Facility
|
IP
|
$3,720.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,083.20 |
| Max. Negotiated Rate |
$3,608.40 |
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,604.00
|
| Rate for Payer: Health Management Network Commercial |
$3,162.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,348.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,608.40
|
| Rate for Payer: University Health Alliance Commercial |
$2,083.20
|
|
|
BRIDGE PLATE BRGP
|
Facility
|
OP
|
$3,720.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,153.20 |
| Max. Negotiated Rate |
$3,608.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,860.00
|
| Rate for Payer: AlohaCare Medicare |
$1,153.20
|
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Devoted Health Medicare |
$1,264.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,153.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,604.00
|
| Rate for Payer: Health Management Network Commercial |
$3,162.00
|
| Rate for Payer: Humana Medicare |
$1,153.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,348.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,897.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,153.20
|
| Rate for Payer: MDX Hawaii PPO |
$3,608.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,153.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,153.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,153.20
|
| Rate for Payer: University Health Alliance Commercial |
$2,083.20
|
|
|
BRITE TIP INTRODUCER 10X11
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$459.00 |
| Max. Negotiated Rate |
$523.80 |
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Health Management Network Commercial |
$459.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$486.00
|
| Rate for Payer: MDX Hawaii PPO |
$523.80
|
|
|
BRITE TIP INTRODUCER 10X11
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.40 |
| Max. Negotiated Rate |
$523.80 |
| Rate for Payer: AlohaCare Medicaid |
$270.00
|
| Rate for Payer: AlohaCare Medicare |
$167.40
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Devoted Health Medicare |
$183.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$167.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$513.00
|
| Rate for Payer: Health Management Network Commercial |
$459.00
|
| Rate for Payer: Humana Medicare |
$167.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$486.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$275.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$167.40
|
| Rate for Payer: MDX Hawaii PPO |
$523.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$167.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$167.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$167.40
|
| Rate for Payer: University Health Alliance Commercial |
$393.61
|
|
|
BRITE TIP INTRODUCER 10X23
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.24 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: AlohaCare Medicaid |
$302.00
|
| Rate for Payer: AlohaCare Medicare |
$187.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Devoted Health Medicare |
$205.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.80
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Humana Medicare |
$187.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.24
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.24
|
| Rate for Payer: University Health Alliance Commercial |
$440.26
|
|
|
BRITE TIP INTRODUCER 10X23
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$513.40 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
|
|
BRITE TIP INTRODUCER 4X23
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.24 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: AlohaCare Medicaid |
$302.00
|
| Rate for Payer: AlohaCare Medicare |
$187.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Devoted Health Medicare |
$205.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.80
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Humana Medicare |
$187.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.24
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.24
|
| Rate for Payer: University Health Alliance Commercial |
$440.26
|
|
|
BRITE TIP INTRODUCER 4X23
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$513.40 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
|
|
BRITE TIP INTRODUCER 5X11
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$43.40
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Devoted Health Medicare |
$47.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$43.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.40
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
|
|
BRITE TIP INTRODUCER 5X11
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
BRITE TIP INTRODUCER 5X23
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$513.40 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
|
|
BRITE TIP INTRODUCER 5X23
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.24 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: AlohaCare Medicaid |
$302.00
|
| Rate for Payer: AlohaCare Medicare |
$187.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Devoted Health Medicare |
$205.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.80
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Humana Medicare |
$187.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.24
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.24
|
| Rate for Payer: University Health Alliance Commercial |
$440.26
|
|
|
BRITE TIP INTRODUCER 6X11
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.24 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: AlohaCare Medicaid |
$302.00
|
| Rate for Payer: AlohaCare Medicare |
$187.24
|
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Devoted Health Medicare |
$205.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.80
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Humana Medicare |
$187.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.24
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.24
|
| Rate for Payer: University Health Alliance Commercial |
$440.26
|
|
|
BRITE TIP INTRODUCER 6X11
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$513.40 |
| Max. Negotiated Rate |
$585.88 |
| Rate for Payer: Cash Price |
$362.40
|
| Rate for Payer: Health Management Network Commercial |
$513.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.60
|
| Rate for Payer: MDX Hawaii PPO |
$585.88
|
|