|
Electrolytes FSI
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 80051
|
| Hospital Charge Code |
8117904
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$48.50
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Cash Price |
$63.05
|
| Rate for Payer: Devoted Health Medicare |
$53.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.69
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$8.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.01
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$48.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.50
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.50
|
| Rate for Payer: University Health Alliance Commercial |
$18.13
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
OP
|
$117.35
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.67 |
| Max. Negotiated Rate |
$113.83 |
| Rate for Payer: AlohaCare Medicaid |
$58.67
|
| Rate for Payer: AlohaCare Medicare |
$58.67
|
| Rate for Payer: Cash Price |
$76.28
|
| Rate for Payer: Devoted Health Medicare |
$64.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$111.48
|
| Rate for Payer: Health Management Network Commercial |
$99.75
|
| Rate for Payer: Humana Medicare |
$58.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.67
|
| Rate for Payer: MDX Hawaii PPO |
$113.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.67
|
| Rate for Payer: University Health Alliance Commercial |
$85.54
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
IP
|
$117.35
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$113.83 |
| Rate for Payer: Cash Price |
$76.28
|
| Rate for Payer: Health Management Network Commercial |
$99.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.61
|
| Rate for Payer: MDX Hawaii PPO |
$113.83
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
IP
|
$113.53
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
|
|
empagliflozin 10 mg tablet [HHSC]
|
Facility
|
OP
|
$113.53
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
2501081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.77 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: AlohaCare Medicaid |
$56.77
|
| Rate for Payer: AlohaCare Medicare |
$56.77
|
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Devoted Health Medicare |
$62.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.85
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Humana Medicare |
$56.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.77
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.77
|
| Rate for Payer: University Health Alliance Commercial |
$82.75
|
|
|
empagliflozin 25 mg tablet [HHSC]
|
Facility
|
OP
|
$113.53
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
2501082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.77 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: AlohaCare Medicaid |
$56.77
|
| Rate for Payer: AlohaCare Medicare |
$56.77
|
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Devoted Health Medicare |
$62.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.85
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Humana Medicare |
$56.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.77
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.77
|
| Rate for Payer: University Health Alliance Commercial |
$82.75
|
|
|
empagliflozin 25 mg tablet [HHSC]
|
Facility
|
IP
|
$113.53
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
2501082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.50 |
| Max. Negotiated Rate |
$110.12 |
| Rate for Payer: Cash Price |
$73.79
|
| Rate for Payer: Health Management Network Commercial |
$96.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.18
|
| Rate for Payer: MDX Hawaii PPO |
$110.12
|
|
|
emtricitabine-tenofovir 200 mg-300 mg tablet [HHSC]
|
Facility
|
IP
|
$203.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$172.59 |
| Max. Negotiated Rate |
$196.96 |
| Rate for Payer: Cash Price |
$131.98
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$172.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.75
|
| Rate for Payer: MDX Hawaii PPO |
$196.96
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
|
|
emtricitabine-tenofovir 200 mg-300 mg tablet [HHSC]
|
Facility
|
OP
|
$12.99
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$101.53
|
| Rate for Payer: AlohaCare Medicaid |
$172.03
|
| Rate for Payer: AlohaCare Medicare |
$101.53
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$172.03
|
| Rate for Payer: Cash Price |
$131.98
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Devoted Health Medicare |
$189.23
|
| Rate for Payer: Devoted Health Medicare |
$111.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$101.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$192.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$326.85
|
| Rate for Payer: Health Management Network Commercial |
$172.59
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Humana Medicare |
$172.03
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Humana Medicare |
$101.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$175.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$101.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.03
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
| Rate for Payer: MDX Hawaii PPO |
$196.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$101.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$101.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$206.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$121.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$101.53
|
| Rate for Payer: University Health Alliance Commercial |
$250.78
|
| Rate for Payer: University Health Alliance Commercial |
$9.47
|
| Rate for Payer: University Health Alliance Commercial |
$148.00
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
NDC 43547054610
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: AlohaCare Medicaid |
$5.14
|
| Rate for Payer: AlohaCare Medicare |
$5.14
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Devoted Health Medicare |
$5.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.78
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Humana Medicare |
$5.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.14
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.14
|
| Rate for Payer: University Health Alliance Commercial |
$7.50
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
NDC 64679092402
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: AlohaCare Medicaid |
$5.14
|
| Rate for Payer: AlohaCare Medicare |
$5.14
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Devoted Health Medicare |
$5.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.78
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Humana Medicare |
$5.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.14
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.14
|
| Rate for Payer: University Health Alliance Commercial |
$7.50
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
IP
|
$10.29
|
|
|
Service Code
|
NDC 43547054610
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
IP
|
$10.29
|
|
|
Service Code
|
NDC 64679092402
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
IP
|
$10.29
|
|
|
Service Code
|
NDC 51079095120
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
NDC 51079095120
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: AlohaCare Medicaid |
$5.14
|
| Rate for Payer: AlohaCare Medicare |
$5.14
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Devoted Health Medicare |
$5.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.78
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Humana Medicare |
$5.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.14
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.14
|
| Rate for Payer: University Health Alliance Commercial |
$7.50
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
NDC 51672403801
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: AlohaCare Medicaid |
$5.14
|
| Rate for Payer: AlohaCare Medicare |
$5.14
|
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Devoted Health Medicare |
$5.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.78
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Humana Medicare |
$5.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.14
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.14
|
| Rate for Payer: University Health Alliance Commercial |
$7.50
|
|
|
enalapril 5 mg tablet [HHSC]
|
Facility
|
IP
|
$10.29
|
|
|
Service Code
|
NDC 51672403801
|
| Hospital Charge Code |
2500287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$9.98 |
| Rate for Payer: Cash Price |
$6.69
|
| Rate for Payer: Health Management Network Commercial |
$8.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: MDX Hawaii PPO |
$9.98
|
|
|
enalaprilat 1.25 mg/1 mL vial [HHSC]
|
Facility
|
OP
|
$20.53
|
|
|
Service Code
|
NDC 00143978710
|
| Hospital Charge Code |
2500286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$19.91 |
| Rate for Payer: AlohaCare Medicaid |
$10.27
|
| Rate for Payer: AlohaCare Medicare |
$10.27
|
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Devoted Health Medicare |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.50
|
| Rate for Payer: Health Management Network Commercial |
$17.45
|
| Rate for Payer: Humana Medicare |
$10.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.27
|
| Rate for Payer: MDX Hawaii PPO |
$19.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.27
|
| Rate for Payer: University Health Alliance Commercial |
$14.96
|
|
|
enalaprilat 1.25 mg/1 mL vial [HHSC]
|
Facility
|
IP
|
$20.53
|
|
|
Service Code
|
NDC 00143978710
|
| Hospital Charge Code |
2500286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.45 |
| Max. Negotiated Rate |
$19.91 |
| Rate for Payer: Cash Price |
$13.34
|
| Rate for Payer: Health Management Network Commercial |
$17.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.48
|
| Rate for Payer: MDX Hawaii PPO |
$19.91
|
|
|
END CAP, 0 MM, ANTEGRADE NAIL
|
Facility
|
OP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.50 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: AlohaCare Medicaid |
$726.50
|
| Rate for Payer: AlohaCare Medicare |
$726.50
|
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Devoted Health Medicare |
$799.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$726.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Humana Medicare |
$726.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$741.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$726.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$726.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$726.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$726.50
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
|
END CAP, 0 MM, ANTEGRADE NAIL
|
Facility
|
IP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985815
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$813.68 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
|
END CAP, ANTEGRADE FEMORAL NAIL, 10 MM
|
Facility
|
IP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985814
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$813.68 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
|
END CAP, ANTEGRADE FEMORAL NAIL, 10 MM
|
Facility
|
OP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985814
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.50 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: AlohaCare Medicaid |
$726.50
|
| Rate for Payer: AlohaCare Medicare |
$726.50
|
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Devoted Health Medicare |
$799.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$726.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Humana Medicare |
$726.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$741.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$726.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$726.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$726.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$726.50
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
|
END CAP, ANTEGRADE FEMORAL NAIL, 5 MM
|
Facility
|
IP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$813.68 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
|
END CAP, ANTEGRADE FEMORAL NAIL, 5 MM
|
Facility
|
OP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$726.50 |
| Max. Negotiated Rate |
$1,409.41 |
| Rate for Payer: AlohaCare Medicaid |
$726.50
|
| Rate for Payer: AlohaCare Medicare |
$726.50
|
| Rate for Payer: Cash Price |
$944.45
|
| Rate for Payer: Devoted Health Medicare |
$799.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$726.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,017.10
|
| Rate for Payer: Health Management Network Commercial |
$1,235.05
|
| Rate for Payer: Humana Medicare |
$726.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,307.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$741.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$726.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,409.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$726.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$726.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$726.50
|
| Rate for Payer: University Health Alliance Commercial |
$813.68
|
|
