|
OT Work Hardening-Initial 2 Hours Units
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
HCPCS 97545 GO
|
| Hospital Charge Code |
1373571
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$260.95 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
|
|
OT Work Hardening-Initial 2 Hours Units
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
HCPCS 97545 GO
|
| Hospital Charge Code |
1373571
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$153.50 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: AlohaCare Medicaid |
$153.50
|
| Rate for Payer: AlohaCare Medicare |
$153.50
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Devoted Health Medicare |
$168.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.65
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Humana Medicare |
$153.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$156.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.50
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.50
|
| Rate for Payer: University Health Alliance Commercial |
$223.77
|
|
|
OT Work Reconditioning Addl Assist Unit
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
HCPCS 97546 GO,CO
|
| Hospital Charge Code |
8743917
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$86.70 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.80
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
|
|
OT Work Reconditioning Addl Assist Unit
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
HCPCS 97546 GO,CO
|
| Hospital Charge Code |
8743917
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: AlohaCare Medicaid |
$51.00
|
| Rate for Payer: AlohaCare Medicare |
$51.00
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Devoted Health Medicare |
$56.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Humana Medicare |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.00
|
| Rate for Payer: University Health Alliance Commercial |
$74.35
|
|
|
OT Work Reconditioning init Assist Units
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
HCPCS 97545 GO,CO
|
| Hospital Charge Code |
8744684
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$153.50 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: AlohaCare Medicaid |
$153.50
|
| Rate for Payer: AlohaCare Medicare |
$153.50
|
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Devoted Health Medicare |
$168.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.65
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Humana Medicare |
$153.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$156.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$153.50
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$153.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.50
|
| Rate for Payer: University Health Alliance Commercial |
$223.77
|
|
|
OT Work Reconditioning init Assist Units
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
HCPCS 97545 GO,CO
|
| Hospital Charge Code |
8744684
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$260.95 |
| Max. Negotiated Rate |
$297.79 |
| Rate for Payer: Cash Price |
$199.55
|
| Rate for Payer: Health Management Network Commercial |
$260.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$276.30
|
| Rate for Payer: MDX Hawaii PPO |
$297.79
|
|
|
Ova and Parasites FSI
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
8118007
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
|
|
Ova and Parasites FSI
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
8118007
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicare |
$64.50
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Cash Price |
$83.85
|
| Rate for Payer: Devoted Health Medicare |
$70.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.30
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$11.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.90
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Humana Medicare |
$64.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.50
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.50
|
| Rate for Payer: University Health Alliance Commercial |
$23.00
|
|
|
oxacillin 2000mg vial [HHSC]
|
Facility
|
IP
|
$135.32
|
|
|
Service Code
|
HCPCS J2700
|
| Hospital Charge Code |
2500620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.02 |
| Max. Negotiated Rate |
$131.26 |
| Rate for Payer: Cash Price |
$87.96
|
| Rate for Payer: Cash Price |
$45.44
|
| Rate for Payer: Cash Price |
$85.16
|
| Rate for Payer: Cash Price |
$88.62
|
| Rate for Payer: Health Management Network Commercial |
$111.36
|
| Rate for Payer: Health Management Network Commercial |
$59.41
|
| Rate for Payer: Health Management Network Commercial |
$115.02
|
| Rate for Payer: Health Management Network Commercial |
$115.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.79
|
| Rate for Payer: MDX Hawaii PPO |
$67.80
|
| Rate for Payer: MDX Hawaii PPO |
$127.08
|
| Rate for Payer: MDX Hawaii PPO |
$131.26
|
| Rate for Payer: MDX Hawaii PPO |
$132.25
|
|
|
oxacillin 2000mg vial [HHSC]
|
Facility
|
OP
|
$135.32
|
|
|
Service Code
|
HCPCS J2700
|
| Hospital Charge Code |
2500620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$131.26 |
| Rate for Payer: AlohaCare Medicaid |
$67.66
|
| Rate for Payer: AlohaCare Medicaid |
$68.17
|
| Rate for Payer: AlohaCare Medicaid |
$65.50
|
| Rate for Payer: AlohaCare Medicaid |
$34.95
|
| Rate for Payer: AlohaCare Medicare |
$34.95
|
| Rate for Payer: AlohaCare Medicare |
$65.50
|
| Rate for Payer: AlohaCare Medicare |
$67.66
|
| Rate for Payer: AlohaCare Medicare |
$68.17
|
| Rate for Payer: Cash Price |
$45.44
|
| Rate for Payer: Cash Price |
$87.96
|
| Rate for Payer: Cash Price |
$85.16
|
| Rate for Payer: Cash Price |
$45.44
|
| Rate for Payer: Cash Price |
$85.16
|
| Rate for Payer: Cash Price |
$88.62
|
| Rate for Payer: Cash Price |
$87.96
|
| Rate for Payer: Cash Price |
$88.62
|
| Rate for Payer: Devoted Health Medicare |
$74.99
|
| Rate for Payer: Devoted Health Medicare |
$74.43
|
| Rate for Payer: Devoted Health Medicare |
$38.45
|
| Rate for Payer: Devoted Health Medicare |
$72.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$67.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$128.55
|
| Rate for Payer: Health Management Network Commercial |
$115.89
|
| Rate for Payer: Health Management Network Commercial |
$111.36
|
| Rate for Payer: Health Management Network Commercial |
$115.02
|
| Rate for Payer: Health Management Network Commercial |
$59.41
|
| Rate for Payer: Humana Medicare |
$65.50
|
| Rate for Payer: Humana Medicare |
$68.17
|
| Rate for Payer: Humana Medicare |
$67.66
|
| Rate for Payer: Humana Medicare |
$34.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.66
|
| Rate for Payer: MDX Hawaii PPO |
$132.25
|
| Rate for Payer: MDX Hawaii PPO |
$127.08
|
| Rate for Payer: MDX Hawaii PPO |
$67.80
|
| Rate for Payer: MDX Hawaii PPO |
$131.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$67.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$67.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$67.66
|
| Rate for Payer: University Health Alliance Commercial |
$95.49
|
| Rate for Payer: University Health Alliance Commercial |
$98.63
|
| Rate for Payer: University Health Alliance Commercial |
$99.38
|
| Rate for Payer: University Health Alliance Commercial |
$50.95
|
|
|
Oxalate, Urine FSI
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 83945
|
| Hospital Charge Code |
8228905
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicare |
$73.50
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Devoted Health Medicare |
$80.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$73.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.50
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.50
|
| Rate for Payer: University Health Alliance Commercial |
$33.28
|
|
|
Oxalate, Urine FSI
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 83945
|
| Hospital Charge Code |
8228905
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$124.95 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: Cash Price |
$95.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
Oxcarbazepine Metabolite, Trileptal, Monohydroxycarbazepine FSI
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
HCPCS 80183
|
| Hospital Charge Code |
8118008
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$78.50
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Devoted Health Medicare |
$86.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.11
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.25
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$78.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.50
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.50
|
| Rate for Payer: University Health Alliance Commercial |
$33.47
|
|
|
Oxcarbazepine Metabolite, Trileptal, Monohydroxycarbazepine FSI
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
HCPCS 80183
|
| Hospital Charge Code |
8118008
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$133.45 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084040001
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.64
|
|
|
Service Code
|
NDC 00904282161
|
| Hospital Charge Code |
2500621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: AlohaCare Medicaid |
$1.82
|
| Rate for Payer: AlohaCare Medicare |
$1.82
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Devoted Health Medicare |
$2.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.46
|
| Rate for Payer: Health Management Network Commercial |
$3.09
|
| Rate for Payer: Humana Medicare |
$1.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.82
|
| Rate for Payer: MDX Hawaii PPO |
$3.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.82
|
| Rate for Payer: University Health Alliance Commercial |
$2.65
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.64
|
|
|
Service Code
|
NDC 00904282161
|
| Hospital Charge Code |
2500621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Health Management Network Commercial |
$3.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.28
|
| Rate for Payer: MDX Hawaii PPO |
$3.53
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084040001
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 69315018201
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 10702020101
|
| Hospital Charge Code |
2500621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: AlohaCare Medicaid |
$2.12
|
| Rate for Payer: AlohaCare Medicare |
$2.12
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Devoted Health Medicare |
$2.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.02
|
| Rate for Payer: Health Management Network Commercial |
$3.60
|
| Rate for Payer: Humana Medicare |
$2.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.12
|
| Rate for Payer: MDX Hawaii PPO |
$4.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.12
|
| Rate for Payer: University Health Alliance Commercial |
$3.08
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 14539065301
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 69315018201
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
2500621
|
|
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
|
|
|
oxybutynin 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 14539065301
|
| Hospital Charge Code |
2500621
|
|
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
|
|
