|
TELESCOPING LAG SCREW, LT, 10.5 X 120MM
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001555
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.20 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 125MM
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.20 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 125MM
|
Facility
|
OP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001557
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,410.00
|
| Rate for Payer: AlohaCare Medicare |
$1,410.00
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Devoted Health Medicare |
$1,551.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,410.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Humana Medicare |
$1,410.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,438.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,410.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,410.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,410.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,410.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 80MM
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.20 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 80MM
|
Facility
|
OP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001556
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,410.00
|
| Rate for Payer: AlohaCare Medicare |
$1,410.00
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Devoted Health Medicare |
$1,551.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,410.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Humana Medicare |
$1,410.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,438.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,410.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,410.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,410.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,410.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 85MM
|
Facility
|
OP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Kaiser Permanente Medicare |
$1,410.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,410.00
|
| Rate for Payer: AlohaCare Medicare |
$1,410.00
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Devoted Health Medicare |
$1,551.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,410.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Humana Medicare |
$1,410.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,438.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,410.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,410.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,410.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 85MM
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001558
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.20 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 90MM
|
Facility
|
IP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001562
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.20 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
TELESCOPING LAG SCREW, LT, 10.5 X 90MM
|
Facility
|
OP
|
$2,820.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13001562
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$2,735.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,410.00
|
| Rate for Payer: AlohaCare Medicare |
$1,410.00
|
| Rate for Payer: Cash Price |
$1,833.00
|
| Rate for Payer: Devoted Health Medicare |
$1,551.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,410.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$2,397.00
|
| Rate for Payer: Humana Medicare |
$1,410.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,538.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,438.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,410.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,735.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,410.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,410.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,410.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,579.20
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 67877014601
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Health Management Network Commercial |
$3.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$4.39
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 51079041820
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$3.85
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
IP
|
$5.44
|
|
|
Service Code
|
NDC 50268077915
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$5.28 |
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Health Management Network Commercial |
$4.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.90
|
| Rate for Payer: MDX Hawaii PPO |
$5.28
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
OP
|
$4.08
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: AlohaCare Medicaid |
$2.04
|
| Rate for Payer: AlohaCare Medicare |
$2.04
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Devoted Health Medicare |
$2.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.88
|
| Rate for Payer: Health Management Network Commercial |
$3.47
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.97
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
IP
|
$4.08
|
|
|
Service Code
|
NDC 00228207610
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Health Management Network Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.67
|
| Rate for Payer: MDX Hawaii PPO |
$3.96
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 51079041820
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: AlohaCare Medicaid |
$1.99
|
| Rate for Payer: AlohaCare Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Devoted Health Medicare |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.77
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Humana Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.99
|
| Rate for Payer: MDX Hawaii PPO |
$3.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.99
|
| Rate for Payer: University Health Alliance Commercial |
$2.89
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 67877014601
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: AlohaCare Medicaid |
$2.27
|
| Rate for Payer: AlohaCare Medicare |
$2.27
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Devoted Health Medicare |
$2.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.30
|
| Rate for Payer: Health Management Network Commercial |
$3.85
|
| Rate for Payer: Humana Medicare |
$2.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.27
|
| Rate for Payer: MDX Hawaii PPO |
$4.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.27
|
| Rate for Payer: University Health Alliance Commercial |
$3.30
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 65162055610
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: AlohaCare Medicaid |
$2.10
|
| Rate for Payer: AlohaCare Medicare |
$2.10
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Devoted Health Medicare |
$2.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.99
|
| Rate for Payer: Health Management Network Commercial |
$3.57
|
| Rate for Payer: Humana Medicare |
$2.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.10
|
| Rate for Payer: MDX Hawaii PPO |
$4.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.10
|
| Rate for Payer: University Health Alliance Commercial |
$3.06
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 65162055610
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Health Management Network Commercial |
$3.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: MDX Hawaii PPO |
$4.07
|
|
|
temazepam 15 mg capsule [HHSC]
|
Facility
|
OP
|
$5.44
|
|
|
Service Code
|
NDC 50268077915
|
| Hospital Charge Code |
2500807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$5.28 |
| Rate for Payer: AlohaCare Medicaid |
$2.72
|
| Rate for Payer: AlohaCare Medicare |
$2.72
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Devoted Health Medicare |
$2.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.17
|
| Rate for Payer: Health Management Network Commercial |
$4.62
|
| Rate for Payer: Humana Medicare |
$2.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.72
|
| Rate for Payer: MDX Hawaii PPO |
$5.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.72
|
| Rate for Payer: University Health Alliance Commercial |
$3.97
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITH MCC
|
Facility
|
IP
|
$19,767.47
|
|
|
Service Code
|
MSDRG 557
|
| Min. Negotiated Rate |
$19,767.47 |
| Max. Negotiated Rate |
$19,767.47 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,767.47
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC
|
Facility
|
IP
|
$19,767.47
|
|
|
Service Code
|
MSDRG 558
|
| Min. Negotiated Rate |
$19,767.47 |
| Max. Negotiated Rate |
$19,767.47 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,767.47
|
|
|
tenecteplase 50 mg kit [HHSC]
|
Facility
|
OP
|
$13,175.34
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
2500808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.94 |
| Max. Negotiated Rate |
$12,780.08 |
| Rate for Payer: AlohaCare Medicaid |
$6,587.67
|
| Rate for Payer: AlohaCare Medicaid |
$6,081.18
|
| Rate for Payer: AlohaCare Medicare |
$6,587.67
|
| Rate for Payer: AlohaCare Medicare |
$6,081.18
|
| Rate for Payer: Cash Price |
$7,905.53
|
| Rate for Payer: Cash Price |
$7,905.53
|
| Rate for Payer: Cash Price |
$8,563.97
|
| Rate for Payer: Cash Price |
$8,563.97
|
| Rate for Payer: Devoted Health Medicare |
$7,246.44
|
| Rate for Payer: Devoted Health Medicare |
$6,689.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$171.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$171.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$246.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$246.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,587.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,081.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$171.94
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$171.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,516.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,554.23
|
| Rate for Payer: Health Management Network Commercial |
$11,199.04
|
| Rate for Payer: Health Management Network Commercial |
$10,338.00
|
| Rate for Payer: Humana Medicare |
$6,081.18
|
| Rate for Payer: Humana Medicare |
$6,587.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,857.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,946.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,202.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,719.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,587.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,081.18
|
| Rate for Payer: MDX Hawaii PPO |
$12,780.08
|
| Rate for Payer: MDX Hawaii PPO |
$11,797.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,081.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,587.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,081.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,587.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,297.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,905.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,081.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,587.67
|
| Rate for Payer: University Health Alliance Commercial |
$9,603.51
|
| Rate for Payer: University Health Alliance Commercial |
$8,865.14
|
|
|
tenecteplase 50 mg kit [HHSC]
|
Facility
|
IP
|
$12,162.35
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
2500808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,338.00 |
| Max. Negotiated Rate |
$11,797.48 |
| Rate for Payer: Cash Price |
$7,905.53
|
| Rate for Payer: Cash Price |
$8,563.97
|
| Rate for Payer: Health Management Network Commercial |
$10,338.00
|
| Rate for Payer: Health Management Network Commercial |
$11,199.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,857.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,946.11
|
| Rate for Payer: MDX Hawaii PPO |
$11,797.48
|
| Rate for Payer: MDX Hawaii PPO |
$12,780.08
|
|
|
TENMO EVOLUTION 14GX11CM (CT)
|
Facility
|
OP
|
$220.00
|
|
| Hospital Charge Code |
9800830
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.00 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: AlohaCare Medicaid |
$110.00
|
| Rate for Payer: AlohaCare Medicare |
$110.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Devoted Health Medicare |
$121.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$209.00
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Humana Medicare |
$110.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$112.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.00
|
| Rate for Payer: University Health Alliance Commercial |
$160.36
|
|
|
TENMO EVOLUTION 14GX11CM (CT)
|
Facility
|
IP
|
$220.00
|
|
| Hospital Charge Code |
9800830
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.00 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
|
