|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 10MM
|
Facility
|
IP
|
$10,500.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879097
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,880.00 |
| Max. Negotiated Rate |
$10,185.00 |
| Rate for Payer: Cash Price |
$6,825.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,350.00
|
| Rate for Payer: Health Management Network Commercial |
$8,925.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,450.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,185.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,880.00
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 12MM
|
Facility
|
IP
|
$10,500.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,880.00 |
| Max. Negotiated Rate |
$10,185.00 |
| Rate for Payer: Cash Price |
$6,825.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,350.00
|
| Rate for Payer: Health Management Network Commercial |
$8,925.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,450.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,185.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,880.00
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 12MM
|
Facility
|
OP
|
$10,500.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879098
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,250.00 |
| Max. Negotiated Rate |
$10,185.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,250.00
|
| Rate for Payer: AlohaCare Medicare |
$5,250.00
|
| Rate for Payer: Cash Price |
$6,825.00
|
| Rate for Payer: Devoted Health Medicare |
$5,775.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,250.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,350.00
|
| Rate for Payer: Health Management Network Commercial |
$8,925.00
|
| Rate for Payer: Humana Medicare |
$5,250.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,450.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,355.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,250.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,185.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,250.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,250.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,250.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,880.00
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 14MM
|
Facility
|
IP
|
$24,990.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879099
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,994.40 |
| Max. Negotiated Rate |
$24,240.30 |
| Rate for Payer: Cash Price |
$16,243.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,493.00
|
| Rate for Payer: Health Management Network Commercial |
$21,241.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$22,491.00
|
| Rate for Payer: MDX Hawaii PPO |
$24,240.30
|
| Rate for Payer: University Health Alliance Commercial |
$13,994.40
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 14MM
|
Facility
|
OP
|
$24,990.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879099
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,495.00 |
| Max. Negotiated Rate |
$24,240.30 |
| Rate for Payer: AlohaCare Medicaid |
$12,495.00
|
| Rate for Payer: AlohaCare Medicare |
$12,495.00
|
| Rate for Payer: Cash Price |
$16,243.50
|
| Rate for Payer: Devoted Health Medicare |
$13,744.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12,495.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,493.00
|
| Rate for Payer: Health Management Network Commercial |
$21,241.50
|
| Rate for Payer: Humana Medicare |
$12,495.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22,491.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12,744.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$12,495.00
|
| Rate for Payer: MDX Hawaii PPO |
$24,240.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,495.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$12,495.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$12,495.00
|
| Rate for Payer: University Health Alliance Commercial |
$13,994.40
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 16MM
|
Facility
|
IP
|
$10,500.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,880.00 |
| Max. Negotiated Rate |
$10,185.00 |
| Rate for Payer: Cash Price |
$6,825.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,350.00
|
| Rate for Payer: Health Management Network Commercial |
$8,925.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,450.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,185.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,880.00
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 16MM
|
Facility
|
OP
|
$10,500.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,250.00 |
| Max. Negotiated Rate |
$10,185.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,250.00
|
| Rate for Payer: AlohaCare Medicare |
$5,250.00
|
| Rate for Payer: Cash Price |
$6,825.00
|
| Rate for Payer: Devoted Health Medicare |
$5,775.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,250.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,350.00
|
| Rate for Payer: Health Management Network Commercial |
$8,925.00
|
| Rate for Payer: Humana Medicare |
$5,250.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,450.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,355.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,250.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,185.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,250.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,250.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,250.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,880.00
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 8MM
|
Facility
|
OP
|
$12,495.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,247.50 |
| Max. Negotiated Rate |
$12,120.15 |
| Rate for Payer: AlohaCare Medicaid |
$6,247.50
|
| Rate for Payer: AlohaCare Medicare |
$6,247.50
|
| Rate for Payer: Cash Price |
$8,121.75
|
| Rate for Payer: Devoted Health Medicare |
$6,872.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,247.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,746.50
|
| Rate for Payer: Health Management Network Commercial |
$10,620.75
|
| Rate for Payer: Humana Medicare |
$6,247.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,245.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,372.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,247.50
|
| Rate for Payer: MDX Hawaii PPO |
$12,120.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,247.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,247.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,247.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,997.20
|
|
|
SPINE & PAIN: VERTIFLEX INDIRECT DECOMPRESSION IMPLANT 8MM
|
Facility
|
IP
|
$12,495.00
|
|
|
Service Code
|
HCPCS C1821
|
| Hospital Charge Code |
8879096
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,997.20 |
| Max. Negotiated Rate |
$12,120.15 |
| Rate for Payer: Cash Price |
$8,121.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,746.50
|
| Rate for Payer: Health Management Network Commercial |
$10,620.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,245.50
|
| Rate for Payer: MDX Hawaii PPO |
$12,120.15
|
| Rate for Payer: University Health Alliance Commercial |
$6,997.20
|
|
|
SPINE & PAIN: VERTIFLEX INSTRUMENT PLATFORM KIT
|
Facility
|
IP
|
$2,085.00
|
|
| Hospital Charge Code |
8879102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,772.25 |
| Max. Negotiated Rate |
$2,022.45 |
| Rate for Payer: Cash Price |
$1,355.25
|
| Rate for Payer: Health Management Network Commercial |
$1,772.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,876.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,022.45
|
|
|
SPINE & PAIN: VERTIFLEX INSTRUMENT PLATFORM KIT
|
Facility
|
OP
|
$2,085.00
|
|
| Hospital Charge Code |
8879102
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.50 |
| Max. Negotiated Rate |
$2,022.45 |
| Rate for Payer: AlohaCare Medicaid |
$1,042.50
|
| Rate for Payer: AlohaCare Medicare |
$1,042.50
|
| Rate for Payer: Cash Price |
$1,355.25
|
| Rate for Payer: Devoted Health Medicare |
$1,146.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,042.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,980.75
|
| Rate for Payer: Health Management Network Commercial |
$1,772.25
|
| Rate for Payer: Humana Medicare |
$1,042.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,876.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,063.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,042.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,022.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,042.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,042.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,042.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,519.76
|
|
|
SPINE & PAIN: VERTIFLEX SUPERION SUI KIT
|
Facility
|
IP
|
$2,535.00
|
|
| Hospital Charge Code |
8879101
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,154.75 |
| Max. Negotiated Rate |
$2,458.95 |
| Rate for Payer: Cash Price |
$1,647.75
|
| Rate for Payer: Health Management Network Commercial |
$2,154.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,281.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,458.95
|
|
|
SPINE & PAIN: VERTIFLEX SUPERION SUI KIT
|
Facility
|
OP
|
$2,535.00
|
|
| Hospital Charge Code |
8879101
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,267.50 |
| Max. Negotiated Rate |
$2,458.95 |
| Rate for Payer: AlohaCare Medicaid |
$1,267.50
|
| Rate for Payer: AlohaCare Medicare |
$1,267.50
|
| Rate for Payer: Cash Price |
$1,647.75
|
| Rate for Payer: Devoted Health Medicare |
$1,394.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,267.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,408.25
|
| Rate for Payer: Health Management Network Commercial |
$2,154.75
|
| Rate for Payer: Humana Medicare |
$1,267.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,281.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,292.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,267.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,458.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,267.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,267.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,267.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,847.76
|
|
|
SPIROMETRY COMPLETE CHARGE
|
Facility
|
OP
|
$522.00
|
|
|
Service Code
|
HCPCS 94010
|
| Hospital Charge Code |
8243401
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$506.34 |
| Rate for Payer: AlohaCare Medicaid |
$261.00
|
| Rate for Payer: AlohaCare Medicare |
$261.00
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Devoted Health Medicare |
$287.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$275.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$261.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$495.90
|
| Rate for Payer: Health Management Network Commercial |
$443.70
|
| Rate for Payer: Humana Medicare |
$261.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$469.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$266.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$261.00
|
| Rate for Payer: MDX Hawaii PPO |
$506.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$261.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$261.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$261.00
|
| Rate for Payer: University Health Alliance Commercial |
$292.32
|
|
|
SPIROMETRY COMPLETE CHARGE
|
Facility
|
IP
|
$522.00
|
|
|
Service Code
|
HCPCS 94010
|
| Hospital Charge Code |
8243401
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$443.70 |
| Max. Negotiated Rate |
$506.34 |
| Rate for Payer: Cash Price |
$339.30
|
| Rate for Payer: Health Management Network Commercial |
$443.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$469.80
|
| Rate for Payer: MDX Hawaii PPO |
$506.34
|
|
|
Spirometry POC
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 94200
|
| Hospital Charge Code |
1019782
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$16.57
|
| Rate for Payer: AlohaCare Medicare |
$18.01
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Cash Price |
$53.30
|
| Rate for Payer: Devoted Health Medicare |
$19.81
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.94
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687046501
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 16729022501
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084020601
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687046501
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084020601
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 16729022501
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
spironolactone 25 mg tab [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
2500789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$43,730.19
|
|
|
Service Code
|
MSDRG 800
|
| Min. Negotiated Rate |
$43,730.19 |
| Max. Negotiated Rate |
$43,730.19 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43,730.19
|
|
