|
tiZANidine 6 mg Cap [KMC]
|
Facility
|
OP
|
$20.62
|
|
|
Service Code
|
NDC 70710111308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: AlohaCare Medicaid |
$10.31
|
| Rate for Payer: AlohaCare Medicare |
$8.66
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$18.97
|
| Rate for Payer: Devoted Health Medicare |
$8.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.59
|
| Rate for Payer: Health Management Network Commercial |
$17.53
|
| Rate for Payer: Humana Medicare |
$8.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$20.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.66
|
| Rate for Payer: University Health Alliance Commercial |
$15.03
|
|
|
TMJ OPEN AND CLOSE MOUTH UNI
|
Facility
|
OP
|
$369.00
|
|
|
Service Code
|
HCPCS 70328
|
| Hospital Charge Code |
424703280
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$357.93 |
| Rate for Payer: AlohaCare Medicaid |
$184.50
|
| Rate for Payer: AlohaCare Medicare |
$154.98
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$339.48
|
| Rate for Payer: Devoted Health Medicare |
$154.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$16.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$154.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Humana Medicare |
$154.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$154.98
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$154.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$154.98
|
| Rate for Payer: University Health Alliance Commercial |
$60.09
|
|
|
TMJ OPEN AND CLOSE MOUTH UNI
|
Facility
|
IP
|
$369.00
|
|
|
Service Code
|
HCPCS 70328
|
| Hospital Charge Code |
424703280
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.65 |
| Max. Negotiated Rate |
$357.93 |
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
|
|
TMJ OPEN OR CLOSED BILATERAL
|
Facility
|
OP
|
$592.00
|
|
|
Service Code
|
HCPCS 70330
|
| Hospital Charge Code |
424703300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$27.83 |
| Max. Negotiated Rate |
$574.24 |
| Rate for Payer: AlohaCare Medicaid |
$296.00
|
| Rate for Payer: AlohaCare Medicare |
$248.64
|
| Rate for Payer: Cash Price |
$384.80
|
| Rate for Payer: Cash Price |
$384.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$544.64
|
| Rate for Payer: Devoted Health Medicare |
$248.64
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$27.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$248.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$503.20
|
| Rate for Payer: Humana Medicare |
$248.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$301.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$248.64
|
| Rate for Payer: MDX Hawaii PPO |
$574.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$248.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$248.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$248.64
|
| Rate for Payer: University Health Alliance Commercial |
$94.79
|
|
|
TMJ OPEN OR CLOSED BILATERAL
|
Facility
|
IP
|
$592.00
|
|
|
Service Code
|
HCPCS 70330
|
| Hospital Charge Code |
424703300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$503.20 |
| Max. Negotiated Rate |
$574.24 |
| Rate for Payer: Cash Price |
$384.80
|
| Rate for Payer: Health Management Network Commercial |
$503.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.80
|
| Rate for Payer: MDX Hawaii PPO |
$574.24
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 99406
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$11.80
|
| Rate for Payer: AlohaCare Medicare |
$10.68
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Devoted Health Medicare |
$10.68
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.50
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
TOBACCO USE CESSATION IVNTJ COUNSELING
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS 4000F
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
TOB NON-USER
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS G9459
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
tobramycin 1200 mg/30 mL Soln [KMC]
|
Facility
|
OP
|
$3.52
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: AlohaCare Medicaid |
$1.76
|
| Rate for Payer: AlohaCare Medicare |
$1.48
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3.24
|
| Rate for Payer: Devoted Health Medicare |
$1.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.34
|
| Rate for Payer: Health Management Network Commercial |
$2.99
|
| Rate for Payer: Humana Medicare |
$1.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.48
|
| Rate for Payer: MDX Hawaii PPO |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.48
|
| Rate for Payer: University Health Alliance Commercial |
$2.57
|
|
|
tobramycin 1200 mg/30 mL Soln [KMC]
|
Facility
|
IP
|
$3.52
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Health Management Network Commercial |
$2.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.17
|
| Rate for Payer: MDX Hawaii PPO |
$3.41
|
|
|
tobramycin Ophth 0.3% Sol [KMC]
|
Facility
|
OP
|
$11.28
|
|
|
Service Code
|
NDC 24208029005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: AlohaCare Medicaid |
$5.64
|
| Rate for Payer: AlohaCare Medicare |
$4.74
|
| Rate for Payer: Cash Price |
$7.33
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$10.38
|
| Rate for Payer: Devoted Health Medicare |
$4.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.72
|
| Rate for Payer: Health Management Network Commercial |
$9.59
|
| Rate for Payer: Humana Medicare |
$4.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.74
|
| Rate for Payer: MDX Hawaii PPO |
$10.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.74
|
| Rate for Payer: University Health Alliance Commercial |
$8.22
|
|
|
tobramycin Ophth 0.3% Sol [KMC]
|
Facility
|
IP
|
$11.28
|
|
|
Service Code
|
NDC 24208029005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Cash Price |
$7.33
|
| Rate for Payer: Health Management Network Commercial |
$9.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.15
|
| Rate for Payer: MDX Hawaii PPO |
$10.94
|
|
|
TOB USER RECD CESS INTERV
|
Professional
|
Both
|
$0.01
|
|
|
Service Code
|
HCPCS G9458
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.89
|
| Rate for Payer: Health Management Network Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
TOES MIN 2 VWS
|
Facility
|
OP
|
$369.00
|
|
|
Service Code
|
HCPCS 73660
|
| Hospital Charge Code |
424736600
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$357.93 |
| Rate for Payer: AlohaCare Medicaid |
$184.50
|
| Rate for Payer: AlohaCare Medicare |
$154.98
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$339.48
|
| Rate for Payer: Devoted Health Medicare |
$154.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$13.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$154.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.81
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Humana Medicare |
$154.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$188.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$154.98
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$154.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$154.98
|
| Rate for Payer: University Health Alliance Commercial |
$53.35
|
|
|
TOES MIN 2 VWS
|
Facility
|
IP
|
$369.00
|
|
|
Service Code
|
HCPCS 73660
|
| Hospital Charge Code |
424736600
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$313.65 |
| Max. Negotiated Rate |
$357.93 |
| Rate for Payer: Cash Price |
$239.85
|
| Rate for Payer: Health Management Network Commercial |
$313.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$332.10
|
| Rate for Payer: MDX Hawaii PPO |
$357.93
|
|
|
tolterodine 2 mg ER Cap [KMC]
|
Facility
|
OP
|
$38.19
|
|
|
Service Code
|
NDC 13668018930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.04 |
| Max. Negotiated Rate |
$37.04 |
| Rate for Payer: AlohaCare Medicaid |
$19.09
|
| Rate for Payer: AlohaCare Medicare |
$16.04
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$35.13
|
| Rate for Payer: Devoted Health Medicare |
$16.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.28
|
| Rate for Payer: Health Management Network Commercial |
$32.46
|
| Rate for Payer: Humana Medicare |
$16.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.04
|
| Rate for Payer: MDX Hawaii PPO |
$37.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.04
|
| Rate for Payer: University Health Alliance Commercial |
$27.84
|
|
|
tolterodine 2 mg ER Cap [KMC]
|
Facility
|
IP
|
$38.19
|
|
|
Service Code
|
NDC 13668018930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.46 |
| Max. Negotiated Rate |
$37.04 |
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Health Management Network Commercial |
$32.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.37
|
| Rate for Payer: MDX Hawaii PPO |
$37.04
|
|
|
tolterodine 4 mg ER Cap [KMC]
|
Facility
|
IP
|
$52.50
|
|
|
Service Code
|
NDC 31722060830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.62 |
| Max. Negotiated Rate |
$50.92 |
| Rate for Payer: Cash Price |
$34.12
|
| Rate for Payer: Health Management Network Commercial |
$44.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.25
|
| Rate for Payer: MDX Hawaii PPO |
$50.92
|
|
|
tolterodine 4 mg ER Cap [KMC]
|
Facility
|
OP
|
$52.50
|
|
|
Service Code
|
NDC 31722060830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$50.92 |
| Rate for Payer: AlohaCare Medicaid |
$26.25
|
| Rate for Payer: AlohaCare Medicare |
$22.05
|
| Rate for Payer: Cash Price |
$34.12
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$48.30
|
| Rate for Payer: Devoted Health Medicare |
$22.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.88
|
| Rate for Payer: Health Management Network Commercial |
$44.62
|
| Rate for Payer: Humana Medicare |
$22.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.05
|
| Rate for Payer: MDX Hawaii PPO |
$50.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.05
|
| Rate for Payer: University Health Alliance Commercial |
$38.27
|
|
|
TOOTHETTE
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
8347
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
TOOTHETTE
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
8347
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$11.76
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$25.76
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$11.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.76
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.76
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
topiramate 100 mg Tab [KMC]
|
Facility
|
OP
|
$27.54
|
|
|
Service Code
|
NDC 69097012403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$26.71 |
| Rate for Payer: AlohaCare Medicaid |
$13.77
|
| Rate for Payer: AlohaCare Medicare |
$11.57
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$25.34
|
| Rate for Payer: Devoted Health Medicare |
$11.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.16
|
| Rate for Payer: Health Management Network Commercial |
$23.41
|
| Rate for Payer: Humana Medicare |
$11.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.57
|
| Rate for Payer: MDX Hawaii PPO |
$26.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.57
|
| Rate for Payer: University Health Alliance Commercial |
$20.07
|
|
|
topiramate 100 mg Tab [KMC]
|
Facility
|
IP
|
$27.54
|
|
|
Service Code
|
NDC 69097012403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$26.71 |
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Health Management Network Commercial |
$23.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.79
|
| Rate for Payer: MDX Hawaii PPO |
$26.71
|
|
|
topiramate 200 mg Tab [KMC]
|
Facility
|
OP
|
$32.25
|
|
|
Service Code
|
NDC 69097012503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: AlohaCare Medicaid |
$16.12
|
| Rate for Payer: AlohaCare Medicare |
$13.54
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$29.67
|
| Rate for Payer: Devoted Health Medicare |
$13.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.64
|
| Rate for Payer: Health Management Network Commercial |
$27.41
|
| Rate for Payer: Humana Medicare |
$13.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.54
|
| Rate for Payer: MDX Hawaii PPO |
$31.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.54
|
| Rate for Payer: University Health Alliance Commercial |
$23.51
|
|
|
topiramate 200 mg Tab [KMC]
|
Facility
|
IP
|
$32.25
|
|
|
Service Code
|
NDC 69097012503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.41 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Health Management Network Commercial |
$27.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.02
|
| Rate for Payer: MDX Hawaii PPO |
$31.28
|
|
