|
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
|
|
|
emtricitabine-tenofovir 200 mg-300 mg tablet [HHSC]
|
Facility
|
OP
|
$203.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.53 |
| Max. Negotiated Rate |
$196.96 |
| Rate for Payer: AlohaCare Medicaid |
$101.53
|
| Rate for Payer: AlohaCare Medicaid |
$172.03
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$172.03
|
| Rate for Payer: AlohaCare Medicare |
$101.53
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$131.98
|
| Rate for Payer: Devoted Health Medicare |
$189.23
|
| Rate for Payer: Devoted Health Medicare |
$111.68
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| 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 |
$12.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$192.90
|
| 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 |
$6.50
|
| Rate for Payer: Humana Medicare |
$172.03
|
| Rate for Payer: Humana Medicare |
$101.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$182.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$175.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.56
|
| 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 |
$101.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.03
|
| 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 |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$121.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$206.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$101.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| 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
|
|
|
emtricitabine-tenofovir 200 mg-300 mg tablet [HHSC]
|
Facility
|
IP
|
$344.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.44 |
| Max. Negotiated Rate |
$333.73 |
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Cash Price |
$131.98
|
| Rate for Payer: Cash Price |
$8.44
|
| 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 |
$182.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$196.96
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
|
|
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
|
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, 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, 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
|
|
|
END CAP, CAPTURED, BULLET TIP, 10 MM
|
Facility
|
OP
|
$1,453.00
|
|
| Hospital Charge Code |
12987412
|
|
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, CAPTURED, BULLET TIP, 10 MM
|
Facility
|
IP
|
$1,453.00
|
|
| Hospital Charge Code |
12987412
|
|
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, CAPTURED, BULLET TIP, 1 MM
|
Facility
|
OP
|
$779.00
|
|
| Hospital Charge Code |
12987411
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$389.50 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: AlohaCare Medicaid |
$389.50
|
| Rate for Payer: AlohaCare Medicare |
$389.50
|
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Devoted Health Medicare |
$428.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$389.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$545.30
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Humana Medicare |
$389.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$397.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$389.50
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$389.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$389.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$389.50
|
| Rate for Payer: University Health Alliance Commercial |
$436.24
|
|
|
END CAP, CAPTURED, BULLET TIP, 1 MM
|
Facility
|
IP
|
$779.00
|
|
| Hospital Charge Code |
12987411
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$436.24 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: Cash Price |
$506.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$545.30
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: University Health Alliance Commercial |
$436.24
|
|
|
END CAP, CAPTURED, BULLET TIP, 5 MM
|
Facility
|
IP
|
$1,453.00
|
|
| Hospital Charge Code |
12987413
|
|
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, CAPTURED, BULLET TIP, 5 MM
|
Facility
|
OP
|
$1,453.00
|
|
| Hospital Charge Code |
12987413
|
|
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, RETROGRADE FEMORAL NAIL, 1 MM
|
Facility
|
OP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987409
|
|
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, RETROGRADE FEMORAL NAIL, 1 MM
|
Facility
|
IP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987409
|
|
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, RETROGRADE FEMORAL NAIL, 5 MM
|
Facility
|
IP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985819
|
|
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, RETROGRADE FEMORAL NAIL, 5 MM
|
Facility
|
OP
|
$1,453.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985819
|
|
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
|
|
|
ENDO CATCH 10MM
|
Facility
|
OP
|
$201.00
|
|
| Hospital Charge Code |
8274226
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.50 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: AlohaCare Medicaid |
$100.50
|
| Rate for Payer: AlohaCare Medicare |
$100.50
|
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Devoted Health Medicare |
$110.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.95
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Humana Medicare |
$100.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.50
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.50
|
| Rate for Payer: University Health Alliance Commercial |
$146.51
|
|
|
ENDO CATCH 10MM
|
Facility
|
IP
|
$201.00
|
|
| Hospital Charge Code |
8274226
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$170.85 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Cash Price |
$130.65
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
|
|
ENDO CLIP, LAPAROSCOPIC 5MM
|
Facility
|
OP
|
$1,117.00
|
|
| Hospital Charge Code |
8274208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$558.50 |
| Max. Negotiated Rate |
$1,083.49 |
| Rate for Payer: AlohaCare Medicaid |
$558.50
|
| Rate for Payer: AlohaCare Medicare |
$558.50
|
| Rate for Payer: Cash Price |
$726.05
|
| Rate for Payer: Devoted Health Medicare |
$614.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$558.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,061.15
|
| Rate for Payer: Health Management Network Commercial |
$949.45
|
| Rate for Payer: Humana Medicare |
$558.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,005.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$569.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$558.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,083.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$558.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$558.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$558.50
|
| Rate for Payer: University Health Alliance Commercial |
$814.18
|
|
|
ENDO CLIP, LAPAROSCOPIC 5MM
|
Facility
|
IP
|
$1,117.00
|
|
| Hospital Charge Code |
8274208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$949.45 |
| Max. Negotiated Rate |
$1,083.49 |
| Rate for Payer: Cash Price |
$726.05
|
| Rate for Payer: Health Management Network Commercial |
$949.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,005.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,083.49
|
|
