|
CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
HCPCS 75833 TC
|
| Min. Negotiated Rate |
$94.99 |
| Max. Negotiated Rate |
$636.14 |
| Rate for Payer: AlohaCare Medicaid |
$94.99
|
| Rate for Payer: AlohaCare Medicare |
$96.09
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Devoted Health Medicare |
$105.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$636.14
|
| Rate for Payer: Health Management Network Commercial |
$151.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$115.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.09
|
|
|
CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$293.00
|
|
|
Service Code
|
HCPCS 75833
|
| Min. Negotiated Rate |
$94.99 |
| Max. Negotiated Rate |
$636.14 |
| Rate for Payer: AlohaCare Medicaid |
$94.99
|
| Rate for Payer: AlohaCare Medicare |
$167.38
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Devoted Health Medicare |
$184.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$167.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$636.14
|
| Rate for Payer: Health Management Network Commercial |
$249.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$200.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$200.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$167.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$167.38
|
|
|
CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
HCPCS 75831
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$616.67 |
| Rate for Payer: AlohaCare Medicaid |
$77.47
|
| Rate for Payer: AlohaCare Medicare |
$128.07
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Devoted Health Medicare |
$140.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.67
|
| Rate for Payer: Health Management Network Commercial |
$190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.07
|
|
|
CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS 75831 26
|
| Min. Negotiated Rate |
$50.21 |
| Max. Negotiated Rate |
$616.67 |
| Rate for Payer: AlohaCare Medicaid |
$77.47
|
| Rate for Payer: AlohaCare Medicare |
$50.21
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Devoted Health Medicare |
$55.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.67
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.21
|
|
|
CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$137.00
|
|
|
Service Code
|
HCPCS 75831 TC
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$616.67 |
| Rate for Payer: AlohaCare Medicaid |
$77.47
|
| Rate for Payer: AlohaCare Medicare |
$77.86
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Cash Price |
$82.20
|
| Rate for Payer: Devoted Health Medicare |
$85.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.67
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.86
|
|
|
CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
HCPCS 75860 TC
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$616.76 |
| Rate for Payer: AlohaCare Medicaid |
$81.60
|
| Rate for Payer: AlohaCare Medicare |
$86.21
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$94.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.76
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.21
|
|
|
CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
HCPCS 75860
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$616.76 |
| Rate for Payer: AlohaCare Medicaid |
$81.60
|
| Rate for Payer: AlohaCare Medicare |
$139.85
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Devoted Health Medicare |
$153.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.76
|
| Rate for Payer: Health Management Network Commercial |
$309.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$167.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$167.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$167.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.85
|
|
|
CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I
|
Professional
|
Both
|
$94.00
|
|
|
Service Code
|
HCPCS 75860 26
|
| Min. Negotiated Rate |
$53.63 |
| Max. Negotiated Rate |
$616.76 |
| Rate for Payer: AlohaCare Medicaid |
$81.60
|
| Rate for Payer: AlohaCare Medicare |
$53.63
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Devoted Health Medicare |
$58.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$616.76
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.63
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00555003302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00555003302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079014120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687080701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00555015902
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687080711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079014120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687080701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00555015902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE [1623]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687080711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 16571012848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 16571012848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$31.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$35.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$31.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.92
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.92
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 00126027216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$24.32
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Humana Medicare |
$24.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.32
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
NDC 00116200116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$482.09 |
| Rate for Payer: AlohaCare Medicaid |
$248.50
|
| Rate for Payer: AlohaCare Medicare |
$377.72
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Devoted Health Medicare |
$417.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$377.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$472.15
|
| Rate for Payer: Health Management Network Commercial |
$422.45
|
| Rate for Payer: Humana Medicare |
$377.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$447.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$253.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$377.72
|
| Rate for Payer: MDX Hawaii PPO |
$482.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$377.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$377.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$377.72
|
| Rate for Payer: University Health Alliance Commercial |
$362.26
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 69339013815
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 69339013815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 69339013817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
