|
PAIN & SPINE PUMP 8637-20 SYNCH II PR PCC=32
|
Facility
|
OP
|
$21,280.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
8805344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,640.00 |
| Max. Negotiated Rate |
$20,641.60 |
| Rate for Payer: AlohaCare Medicaid |
$10,640.00
|
| Rate for Payer: AlohaCare Medicare |
$10,640.00
|
| Rate for Payer: Cash Price |
$13,832.00
|
| Rate for Payer: Devoted Health Medicare |
$11,704.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,640.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,896.00
|
| Rate for Payer: Health Management Network Commercial |
$18,088.00
|
| Rate for Payer: Humana Medicare |
$10,640.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$19,152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,852.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,640.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,641.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,640.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,640.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,640.00
|
| Rate for Payer: University Health Alliance Commercial |
$11,916.80
|
|
|
PAIN & SPINE PUMP 8637-20 SYNCH II PR PCC=32
|
Facility
|
IP
|
$21,280.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
8805344
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,916.80 |
| Max. Negotiated Rate |
$20,641.60 |
| Rate for Payer: Cash Price |
$13,832.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,896.00
|
| Rate for Payer: Health Management Network Commercial |
$18,088.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$19,152.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,641.60
|
| Rate for Payer: University Health Alliance Commercial |
$11,916.80
|
|
|
PAIN & SPINE PUMP 8637-40 SYNCH II PR PCC=32
|
Facility
|
OP
|
$21,280.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
8805345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,640.00 |
| Max. Negotiated Rate |
$20,641.60 |
| Rate for Payer: AlohaCare Medicaid |
$10,640.00
|
| Rate for Payer: AlohaCare Medicare |
$10,640.00
|
| Rate for Payer: Cash Price |
$13,832.00
|
| Rate for Payer: Devoted Health Medicare |
$11,704.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,640.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,896.00
|
| Rate for Payer: Health Management Network Commercial |
$18,088.00
|
| Rate for Payer: Humana Medicare |
$10,640.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$19,152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,852.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,640.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,641.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,640.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,640.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,640.00
|
| Rate for Payer: University Health Alliance Commercial |
$11,916.80
|
|
|
PAIN & SPINE PUMP 8637-40 SYNCH II PR PCC=32
|
Facility
|
IP
|
$21,280.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
8805345
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,916.80 |
| Max. Negotiated Rate |
$20,641.60 |
| Rate for Payer: Cash Price |
$13,832.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,896.00
|
| Rate for Payer: Health Management Network Commercial |
$18,088.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$19,152.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,641.60
|
| Rate for Payer: University Health Alliance Commercial |
$11,916.80
|
|
|
PAIN & SPINE: SpineJack Case Kit 4.2MM
|
Facility
|
OP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.50 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: AlohaCare Medicaid |
$3,748.50
|
| Rate for Payer: AlohaCare Medicare |
$3,748.50
|
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Devoted Health Medicare |
$4,123.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,748.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Humana Medicare |
$3,748.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,823.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,748.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,748.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,748.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,748.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: SpineJack Case Kit 4.2MM
|
Facility
|
IP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,198.32 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: SpineJack Case Kit 5.0MM
|
Facility
|
IP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,198.32 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: SpineJack Case Kit 5.0MM
|
Facility
|
OP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.50 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: AlohaCare Medicaid |
$3,748.50
|
| Rate for Payer: AlohaCare Medicare |
$3,748.50
|
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Devoted Health Medicare |
$4,123.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,748.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Humana Medicare |
$3,748.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,823.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,748.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,748.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,748.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,748.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: SpineJack Case Kit 5.8MM
|
Facility
|
IP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,198.32 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: SpineJack Case Kit 5.8MM
|
Facility
|
OP
|
$7,497.00
|
|
|
Service Code
|
HCPCS C1062
|
| Hospital Charge Code |
11511783
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.50 |
| Max. Negotiated Rate |
$7,272.09 |
| Rate for Payer: AlohaCare Medicaid |
$3,748.50
|
| Rate for Payer: AlohaCare Medicare |
$3,748.50
|
| Rate for Payer: Cash Price |
$4,873.05
|
| Rate for Payer: Devoted Health Medicare |
$4,123.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,748.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,247.90
|
| Rate for Payer: Health Management Network Commercial |
$6,372.45
|
| Rate for Payer: Humana Medicare |
$3,748.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,747.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,823.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,748.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,272.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,748.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,748.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,748.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.32
|
|
|
PAIN & SPINE: THERMOGARD
|
Facility
|
OP
|
$188.00
|
|
| Hospital Charge Code |
9337527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$182.36 |
| Rate for Payer: AlohaCare Medicaid |
$94.00
|
| Rate for Payer: AlohaCare Medicare |
$94.00
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Devoted Health Medicare |
$103.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$178.60
|
| Rate for Payer: Health Management Network Commercial |
$159.80
|
| Rate for Payer: Humana Medicare |
$94.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$169.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$94.00
|
| Rate for Payer: MDX Hawaii PPO |
$182.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.00
|
| Rate for Payer: University Health Alliance Commercial |
$137.03
|
|
|
PAIN & SPINE: THERMOGARD
|
Facility
|
IP
|
$188.00
|
|
| Hospital Charge Code |
9337527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.80 |
| Max. Negotiated Rate |
$182.36 |
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Health Management Network Commercial |
$159.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$169.20
|
| Rate for Payer: MDX Hawaii PPO |
$182.36
|
|
|
PAIN & SPINE VECTRIS PERM LEAD KIT
|
Facility
|
OP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,200.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,200.00
|
| Rate for Payer: AlohaCare Medicare |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Devoted Health Medicare |
$2,420.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Humana Medicare |
$2,200.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,244.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,200.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,200.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,200.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,200.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
PAIN & SPINE VECTRIS PERM LEAD KIT
|
Facility
|
IP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
PAIN & SPINE VECTRIS TRIAL LEAD KIT
|
Facility
|
OP
|
$2,700.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,350.00
|
| Rate for Payer: AlohaCare Medicare |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Devoted Health Medicare |
$1,485.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,350.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Humana Medicare |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,377.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,350.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,350.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,350.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
PAIN & SPINE VECTRIS TRIAL LEAD KIT
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
PAIN & SPINE: VIADISC NP INJECTION (100MG)
|
Facility
|
OP
|
$18,000.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
10674516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,000.00 |
| Max. Negotiated Rate |
$17,460.00 |
| Rate for Payer: AlohaCare Medicaid |
$9,000.00
|
| Rate for Payer: AlohaCare Medicare |
$9,000.00
|
| Rate for Payer: Cash Price |
$11,700.00
|
| Rate for Payer: Devoted Health Medicare |
$9,900.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,000.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,600.00
|
| Rate for Payer: Health Management Network Commercial |
$15,300.00
|
| Rate for Payer: Humana Medicare |
$9,000.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,200.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,180.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,000.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,460.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,000.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,000.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,000.00
|
| Rate for Payer: University Health Alliance Commercial |
$10,080.00
|
|
|
PAIN & SPINE: VIADISC NP INJECTION (100MG)
|
Facility
|
IP
|
$18,000.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
10674516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,080.00 |
| Max. Negotiated Rate |
$17,460.00 |
| Rate for Payer: Cash Price |
$11,700.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,600.00
|
| Rate for Payer: Health Management Network Commercial |
$15,300.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,200.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,460.00
|
| Rate for Payer: University Health Alliance Commercial |
$10,080.00
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
OP
|
$146.04
|
|
|
Service Code
|
NDC 27808022301
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.02 |
| Max. Negotiated Rate |
$141.66 |
| Rate for Payer: AlohaCare Medicaid |
$73.02
|
| Rate for Payer: AlohaCare Medicare |
$73.02
|
| Rate for Payer: Cash Price |
$94.93
|
| Rate for Payer: Devoted Health Medicare |
$80.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$138.74
|
| Rate for Payer: Health Management Network Commercial |
$124.13
|
| Rate for Payer: Humana Medicare |
$73.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.02
|
| Rate for Payer: MDX Hawaii PPO |
$141.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.02
|
| Rate for Payer: University Health Alliance Commercial |
$106.45
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
IP
|
$146.04
|
|
|
Service Code
|
NDC 27808022301
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.13 |
| Max. Negotiated Rate |
$141.66 |
| Rate for Payer: Cash Price |
$94.93
|
| Rate for Payer: Health Management Network Commercial |
$124.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.44
|
| Rate for Payer: MDX Hawaii PPO |
$141.66
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
OP
|
$145.90
|
|
|
Service Code
|
NDC 47335076583
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.95 |
| Max. Negotiated Rate |
$141.52 |
| Rate for Payer: AlohaCare Medicaid |
$72.95
|
| Rate for Payer: AlohaCare Medicare |
$72.95
|
| Rate for Payer: Cash Price |
$94.84
|
| Rate for Payer: Devoted Health Medicare |
$80.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$138.60
|
| Rate for Payer: Health Management Network Commercial |
$124.02
|
| Rate for Payer: Humana Medicare |
$72.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.95
|
| Rate for Payer: MDX Hawaii PPO |
$141.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.95
|
| Rate for Payer: University Health Alliance Commercial |
$106.35
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
IP
|
$146.04
|
|
|
Service Code
|
NDC 65162028103
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.13 |
| Max. Negotiated Rate |
$141.66 |
| Rate for Payer: Cash Price |
$94.93
|
| Rate for Payer: Health Management Network Commercial |
$124.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.44
|
| Rate for Payer: MDX Hawaii PPO |
$141.66
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
IP
|
$145.90
|
|
|
Service Code
|
NDC 47335076583
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.02 |
| Max. Negotiated Rate |
$141.52 |
| Rate for Payer: Cash Price |
$94.84
|
| Rate for Payer: Health Management Network Commercial |
$124.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.31
|
| Rate for Payer: MDX Hawaii PPO |
$141.52
|
|
|
paliperidone ER 3 mg tablet [HHSC]
|
Facility
|
OP
|
$146.04
|
|
|
Service Code
|
NDC 65162028103
|
| Hospital Charge Code |
2500632
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.02 |
| Max. Negotiated Rate |
$141.66 |
| Rate for Payer: AlohaCare Medicaid |
$73.02
|
| Rate for Payer: AlohaCare Medicare |
$73.02
|
| Rate for Payer: Cash Price |
$94.93
|
| Rate for Payer: Devoted Health Medicare |
$80.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$138.74
|
| Rate for Payer: Health Management Network Commercial |
$124.13
|
| Rate for Payer: Humana Medicare |
$73.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.02
|
| Rate for Payer: MDX Hawaii PPO |
$141.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.02
|
| Rate for Payer: University Health Alliance Commercial |
$106.45
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$51,646.66
|
|
|
Service Code
|
MSDRG 406
|
| Min. Negotiated Rate |
$51,646.66 |
| Max. Negotiated Rate |
$51,646.66 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,646.66
|
|
