|
TAPER POST SHLDR 8156-0032-A
|
Facility
|
IP
|
$2,436.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,364.16 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,705.20
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,192.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,364.16
|
|
|
TAPER POST SHLDR 8156-0032-A
|
Facility
|
OP
|
$2,436.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$755.16 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: AlohaCare Medicaid |
$1,218.00
|
| Rate for Payer: AlohaCare Medicare |
$755.16
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Devoted Health Medicare |
$828.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$755.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,705.20
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: Humana Medicare |
$755.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,192.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,242.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$755.16
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$755.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$755.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$755.16
|
| Rate for Payer: University Health Alliance Commercial |
$1,364.16
|
|
|
TAP QC 2.7X100 4811-100-27
|
Facility
|
OP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: AlohaCare Medicaid |
$300.00
|
| Rate for Payer: AlohaCare Medicare |
$186.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Devoted Health Medicare |
$204.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Humana Medicare |
$186.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.00
|
| Rate for Payer: University Health Alliance Commercial |
$437.34
|
|
|
TAP QC 2.7X100 4811-100-27
|
Facility
|
IP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
|
|
TAP QC 3.5X110MM 4811-110-35
|
Facility
|
OP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.53 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: AlohaCare Medicaid |
$281.50
|
| Rate for Payer: AlohaCare Medicare |
$174.53
|
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Devoted Health Medicare |
$191.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$534.85
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Humana Medicare |
$174.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$287.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.53
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.53
|
| Rate for Payer: University Health Alliance Commercial |
$410.37
|
|
|
TAP QC 3.5X110MM 4811-110-35
|
Facility
|
IP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.55 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
|
|
TAP QC 4.0X110MM 4811-110-40
|
Facility
|
OP
|
$675.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$209.25 |
| Max. Negotiated Rate |
$654.75 |
| Rate for Payer: AlohaCare Medicaid |
$337.50
|
| Rate for Payer: AlohaCare Medicare |
$209.25
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Devoted Health Medicare |
$229.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$641.25
|
| Rate for Payer: Health Management Network Commercial |
$573.75
|
| Rate for Payer: Humana Medicare |
$209.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$607.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$344.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.25
|
| Rate for Payer: MDX Hawaii PPO |
$654.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$209.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$209.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.25
|
| Rate for Payer: University Health Alliance Commercial |
$492.01
|
|
|
TAP QC 4.0X110MM 4811-110-40
|
Facility
|
IP
|
$675.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$573.75 |
| Max. Negotiated Rate |
$654.75 |
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Health Management Network Commercial |
$573.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$607.50
|
| Rate for Payer: MDX Hawaii PPO |
$654.75
|
|
|
TARLATAMAB-DLLE 10 MG INTRAVENOUS SOLUTION [198533]
|
Facility
|
IP
|
$18,500.00
|
|
|
Service Code
|
HCPCS J9026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15,725.00 |
| Max. Negotiated Rate |
$17,945.00 |
| Rate for Payer: Cash Price |
$11,100.00
|
| Rate for Payer: Health Management Network Commercial |
$15,725.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,650.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,945.00
|
|
|
T-CLAMP FOR 2/3MM PINS M104
|
Facility
|
IP
|
$608.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.80 |
| Max. Negotiated Rate |
$589.76 |
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Health Management Network Commercial |
$516.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$547.20
|
| Rate for Payer: MDX Hawaii PPO |
$589.76
|
|
|
T-CLAMP FOR 2/3MM PINS M104
|
Facility
|
OP
|
$608.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.48 |
| Max. Negotiated Rate |
$589.76 |
| Rate for Payer: AlohaCare Medicaid |
$304.00
|
| Rate for Payer: AlohaCare Medicare |
$188.48
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Devoted Health Medicare |
$206.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$577.60
|
| Rate for Payer: Health Management Network Commercial |
$516.80
|
| Rate for Payer: Humana Medicare |
$188.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$547.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$310.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.48
|
| Rate for Payer: MDX Hawaii PPO |
$589.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$188.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.48
|
| Rate for Payer: University Health Alliance Commercial |
$443.17
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268077915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268077911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268077915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 67877014601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268077911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 67877014601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
TEMNO ACT 20X15 BIOSPY
|
Facility
|
OP
|
$234.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.54 |
| Max. Negotiated Rate |
$226.98 |
| Rate for Payer: AlohaCare Medicaid |
$117.00
|
| Rate for Payer: AlohaCare Medicare |
$72.54
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Devoted Health Medicare |
$79.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$222.30
|
| Rate for Payer: Health Management Network Commercial |
$198.90
|
| Rate for Payer: Humana Medicare |
$72.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$210.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$119.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.54
|
| Rate for Payer: MDX Hawaii PPO |
$226.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.54
|
| Rate for Payer: University Health Alliance Commercial |
$170.56
|
|
|
TEMNO ACT 20X15 BIOSPY
|
Facility
|
IP
|
$234.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$226.98 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Health Management Network Commercial |
$198.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$210.60
|
| Rate for Payer: MDX Hawaii PPO |
$226.98
|
|
|
TEMNO ACT 20X20 BIOSPY
|
Facility
|
IP
|
$237.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.45 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$213.30
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
|
|
TEMNO ACT 20X20 BIOSPY
|
Facility
|
OP
|
$237.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.47 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: AlohaCare Medicaid |
$118.50
|
| Rate for Payer: AlohaCare Medicare |
$73.47
|
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Devoted Health Medicare |
$80.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$225.15
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Humana Medicare |
$73.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$213.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.47
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.47
|
| Rate for Payer: University Health Alliance Commercial |
$172.75
|
|
|
TEMNO ACT 22X15 BIOSPY
|
Facility
|
OP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.40 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: AlohaCare Medicaid |
$120.00
|
| Rate for Payer: AlohaCare Medicare |
$74.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Devoted Health Medicare |
$81.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Humana Medicare |
$74.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.40
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.40
|
| Rate for Payer: University Health Alliance Commercial |
$174.94
|
|
|
TEMNO ACT 22X15 BIOSPY
|
Facility
|
IP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
|
|
TEMPLATE CALCANEAL KIT M224
|
Facility
|
OP
|
$977.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$302.87 |
| Max. Negotiated Rate |
$947.69 |
| Rate for Payer: AlohaCare Medicaid |
$488.50
|
| Rate for Payer: AlohaCare Medicare |
$302.87
|
| Rate for Payer: Cash Price |
$586.20
|
| Rate for Payer: Devoted Health Medicare |
$332.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$302.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$928.15
|
| Rate for Payer: Health Management Network Commercial |
$830.45
|
| Rate for Payer: Humana Medicare |
$302.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$879.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$498.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$302.87
|
| Rate for Payer: MDX Hawaii PPO |
$947.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$302.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$302.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$302.87
|
| Rate for Payer: University Health Alliance Commercial |
$712.14
|
|
|
TEMPLATE CALCANEAL KIT M224
|
Facility
|
IP
|
$977.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$830.45 |
| Max. Negotiated Rate |
$947.69 |
| Rate for Payer: Cash Price |
$586.20
|
| Rate for Payer: Health Management Network Commercial |
$830.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$879.30
|
| Rate for Payer: MDX Hawaii PPO |
$947.69
|
|
