|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
NDC 65862093090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.26 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: AlohaCare Medicaid |
$23.00
|
| Rate for Payer: AlohaCare Medicare |
$14.26
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Devoted Health Medicare |
$15.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.70
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Humana Medicare |
$14.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.26
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.26
|
| Rate for Payer: University Health Alliance Commercial |
$33.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
NDC 33342028868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.26 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: AlohaCare Medicaid |
$23.00
|
| Rate for Payer: AlohaCare Medicare |
$14.26
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Devoted Health Medicare |
$15.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.70
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Humana Medicare |
$14.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.26
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.26
|
| Rate for Payer: University Health Alliance Commercial |
$33.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00115136530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$15.19
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Devoted Health Medicare |
$16.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$15.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.19
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.19
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 00115136530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
NDC 65862093090
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
NDC 33342028868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 50268072015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 50268072015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 50268072011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687032865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687032865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$7.75
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$8.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$7.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.75
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 50268072011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
SEVOFLURANE 99.97 % INHALATION LIQUID [15119]
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
NDC 66794001525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.25 |
| Max. Negotiated Rate |
$198.85 |
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Health Management Network Commercial |
$174.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.50
|
| Rate for Payer: MDX Hawaii PPO |
$198.85
|
|
|
SFC COMBO 24/14MM SFCBP.24/14
|
Facility
|
IP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.08 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,433.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC COMBO 24/14MM SFCBP.24/14
|
Facility
|
OP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$493.83 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: AlohaCare Medicaid |
$796.50
|
| Rate for Payer: AlohaCare Medicare |
$493.83
|
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Devoted Health Medicare |
$541.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$493.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Humana Medicare |
$493.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,433.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$812.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$493.83
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$493.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$493.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$493.83
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC COMBO 27/14MM SFCBP.27/14
|
Facility
|
IP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.08 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,433.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC COMBO 27/14MM SFCBP.27/14
|
Facility
|
OP
|
$1,593.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$493.83 |
| Max. Negotiated Rate |
$1,545.21 |
| Rate for Payer: AlohaCare Medicaid |
$796.50
|
| Rate for Payer: AlohaCare Medicare |
$493.83
|
| Rate for Payer: Cash Price |
$955.80
|
| Rate for Payer: Devoted Health Medicare |
$541.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$493.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,115.10
|
| Rate for Payer: Health Management Network Commercial |
$1,354.05
|
| Rate for Payer: Humana Medicare |
$493.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,433.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$812.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$493.83
|
| Rate for Payer: MDX Hawaii PPO |
$1,545.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$493.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$493.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$493.83
|
| Rate for Payer: University Health Alliance Commercial |
$892.08
|
|
|
SFC IN COM 24/10MM SFCIC.24/10
|
Facility
|
IP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$725.20 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
SFC IN COM 24/10MM SFCIC.24/10
|
Facility
|
OP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.45 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: AlohaCare Medicaid |
$647.50
|
| Rate for Payer: AlohaCare Medicare |
$401.45
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Devoted Health Medicare |
$440.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$401.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Humana Medicare |
$401.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$660.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$401.45
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$401.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$401.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$401.45
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
SFC IN COM 24/14MM SFCIC.24/14
|
Facility
|
IP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$725.20 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
SFC IN COM 24/14MM SFCIC.24/14
|
Facility
|
OP
|
$1,295.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.45 |
| Max. Negotiated Rate |
$1,256.15 |
| Rate for Payer: AlohaCare Medicaid |
$647.50
|
| Rate for Payer: AlohaCare Medicare |
$401.45
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Devoted Health Medicare |
$440.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$401.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$906.50
|
| Rate for Payer: Health Management Network Commercial |
$1,100.75
|
| Rate for Payer: Humana Medicare |
$401.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,165.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$660.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$401.45
|
| Rate for Payer: MDX Hawaii PPO |
$1,256.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$401.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$401.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$401.45
|
| Rate for Payer: University Health Alliance Commercial |
$725.20
|
|
|
SFC OUTER COM 28MM SFCOC.28/28
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$568.40 |
| Max. Negotiated Rate |
$984.55 |
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.50
|
| Rate for Payer: Health Management Network Commercial |
$862.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$913.50
|
| Rate for Payer: MDX Hawaii PPO |
$984.55
|
| Rate for Payer: University Health Alliance Commercial |
$568.40
|
|
|
SFC OUTER COM 28MM SFCOC.28/28
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$314.65 |
| Max. Negotiated Rate |
$984.55 |
| Rate for Payer: AlohaCare Medicaid |
$507.50
|
| Rate for Payer: AlohaCare Medicare |
$314.65
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Devoted Health Medicare |
$345.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$314.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.50
|
| Rate for Payer: Health Management Network Commercial |
$862.75
|
| Rate for Payer: Humana Medicare |
$314.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$913.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$517.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$314.65
|
| Rate for Payer: MDX Hawaii PPO |
$984.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$314.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$314.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$314.65
|
| Rate for Payer: University Health Alliance Commercial |
$568.40
|
|
|
SFC OUTER COM 32MM SFCOC.32/32
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$314.65 |
| Max. Negotiated Rate |
$984.55 |
| Rate for Payer: AlohaCare Medicaid |
$507.50
|
| Rate for Payer: AlohaCare Medicare |
$314.65
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Devoted Health Medicare |
$345.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$314.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.50
|
| Rate for Payer: Health Management Network Commercial |
$862.75
|
| Rate for Payer: Humana Medicare |
$314.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$913.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$517.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$314.65
|
| Rate for Payer: MDX Hawaii PPO |
$984.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$314.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$314.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$314.65
|
| Rate for Payer: University Health Alliance Commercial |
$568.40
|
|
|
SFC OUTER COM 32MM SFCOC.32/32
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$568.40 |
| Max. Negotiated Rate |
$984.55 |
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.50
|
| Rate for Payer: Health Management Network Commercial |
$862.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$913.50
|
| Rate for Payer: MDX Hawaii PPO |
$984.55
|
| Rate for Payer: University Health Alliance Commercial |
$568.40
|
|
