|
water for injection, sterile 10ml [HHSC]
|
Facility
|
IP
|
$7.62
|
|
|
Service Code
|
NDC 00409002410
|
| Hospital Charge Code |
2500793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Health Management Network Commercial |
$6.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.86
|
| Rate for Payer: MDX Hawaii PPO |
$7.39
|
|
|
water for injection, sterile 10ml [HHSC]
|
Facility
|
OP
|
$20.82
|
|
|
Service Code
|
NDC 00641614710
|
| Hospital Charge Code |
2500793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$20.20 |
| Rate for Payer: AlohaCare Medicaid |
$10.41
|
| Rate for Payer: AlohaCare Medicare |
$10.41
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Devoted Health Medicare |
$11.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.78
|
| Rate for Payer: Health Management Network Commercial |
$17.70
|
| Rate for Payer: Humana Medicare |
$10.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.41
|
| Rate for Payer: MDX Hawaii PPO |
$20.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.41
|
| Rate for Payer: University Health Alliance Commercial |
$15.18
|
|
|
water for injection, sterile 10ml [HHSC]
|
Facility
|
OP
|
$23.29
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
2500793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.64 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: AlohaCare Medicaid |
$11.64
|
| Rate for Payer: AlohaCare Medicare |
$11.64
|
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Devoted Health Medicare |
$12.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.13
|
| Rate for Payer: Health Management Network Commercial |
$19.80
|
| Rate for Payer: Humana Medicare |
$11.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$22.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$16.98
|
|
|
water for injection, sterile 20ml [HHSC]
|
Facility
|
IP
|
$7.57
|
|
|
Service Code
|
HCPCS A4217
|
| Hospital Charge Code |
2500792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Health Management Network Commercial |
$6.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.81
|
| Rate for Payer: MDX Hawaii PPO |
$7.34
|
|
|
water for injection, sterile 20ml [HHSC]
|
Facility
|
OP
|
$7.57
|
|
|
Service Code
|
HCPCS A4217
|
| Hospital Charge Code |
2500792
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$7.34 |
| Rate for Payer: AlohaCare Medicaid |
$3.79
|
| Rate for Payer: AlohaCare Medicare |
$3.79
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Devoted Health Medicare |
$4.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.19
|
| Rate for Payer: Health Management Network Commercial |
$6.43
|
| Rate for Payer: Humana Medicare |
$3.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.79
|
| Rate for Payer: MDX Hawaii PPO |
$7.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.52
|
|
|
WBC Count FSI
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 85048
|
| Hospital Charge Code |
8128161
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicare |
$18.50
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Devoted Health Medicare |
$20.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$3.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.54
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Humana Medicare |
$18.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.50
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.50
|
| Rate for Payer: University Health Alliance Commercial |
$6.57
|
|
|
WBC Count FSI
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS 85048
|
| Hospital Charge Code |
8128161
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: Cash Price |
$24.05
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
|
|
Wet Prep FSI
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS Q0111
|
| Hospital Charge Code |
8128163
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$5.90 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: AlohaCare Medicaid |
$34.50
|
| Rate for Payer: AlohaCare Medicare |
$34.50
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Devoted Health Medicare |
$37.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.55
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Humana Medicare |
$34.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.50
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.50
|
| Rate for Payer: University Health Alliance Commercial |
$50.29
|
|
|
Wet Prep FSI
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS Q0111
|
| Hospital Charge Code |
8128163
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$66.93 |
| Rate for Payer: Cash Price |
$44.85
|
| Rate for Payer: Health Management Network Commercial |
$58.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.10
|
| Rate for Payer: MDX Hawaii PPO |
$66.93
|
|
|
Wheelchair Charge
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
8123841
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
Wheelchair Charge
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
8123841
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$128.50
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Devoted Health Medicare |
$141.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$128.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.50
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.50
|
| Rate for Payer: University Health Alliance Commercial |
$187.33
|
|
|
Wheelchair Management Charges
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
8111696
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
Wheelchair Management Charges
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
8111696
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$128.50
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Cash Price |
$167.05
|
| Rate for Payer: Devoted Health Medicare |
$141.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$128.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.50
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.50
|
| Rate for Payer: University Health Alliance Commercial |
$187.33
|
|
|
Whirlpool Extremity Charge
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
8123848
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$11.89 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Devoted Health Medicare |
$69.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
Whirlpool Extremity Charge
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
8123848
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
Whirlpool Full Body Charge
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS 97022 GP
|
| Hospital Charge Code |
8111729
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
Whirlpool Full Body Charge
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 97022 GP
|
| Hospital Charge Code |
8111729
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$11.89 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Devoted Health Medicare |
$69.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
IP
|
$72.45
|
|
|
Service Code
|
NDC 46122075737
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.58 |
| Max. Negotiated Rate |
$70.28 |
| Rate for Payer: Cash Price |
$47.09
|
| Rate for Payer: Health Management Network Commercial |
$61.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.20
|
| Rate for Payer: MDX Hawaii PPO |
$70.28
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
IP
|
$41.29
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$40.05 |
| Rate for Payer: Cash Price |
$26.84
|
| Rate for Payer: Health Management Network Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.16
|
| Rate for Payer: MDX Hawaii PPO |
$40.05
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
IP
|
$59.84
|
|
|
Service Code
|
NDC 00023024004
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$58.04 |
| Rate for Payer: Cash Price |
$38.90
|
| Rate for Payer: Health Management Network Commercial |
$50.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.86
|
| Rate for Payer: MDX Hawaii PPO |
$58.04
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
OP
|
$21.57
|
|
|
Service Code
|
NDC 17478006235
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$20.92 |
| Rate for Payer: AlohaCare Medicaid |
$10.79
|
| Rate for Payer: AlohaCare Medicare |
$10.79
|
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Devoted Health Medicare |
$11.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.49
|
| Rate for Payer: Health Management Network Commercial |
$18.33
|
| Rate for Payer: Humana Medicare |
$10.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.79
|
| Rate for Payer: MDX Hawaii PPO |
$20.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.79
|
| Rate for Payer: University Health Alliance Commercial |
$15.72
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
OP
|
$59.84
|
|
|
Service Code
|
NDC 00023024004
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.92 |
| Max. Negotiated Rate |
$58.04 |
| Rate for Payer: AlohaCare Medicaid |
$29.92
|
| Rate for Payer: AlohaCare Medicare |
$29.92
|
| Rate for Payer: Cash Price |
$38.90
|
| Rate for Payer: Devoted Health Medicare |
$32.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.85
|
| Rate for Payer: Health Management Network Commercial |
$50.86
|
| Rate for Payer: Humana Medicare |
$29.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.92
|
| Rate for Payer: MDX Hawaii PPO |
$58.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.92
|
| Rate for Payer: University Health Alliance Commercial |
$43.62
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
OP
|
$41.29
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$40.05 |
| Rate for Payer: AlohaCare Medicaid |
$20.64
|
| Rate for Payer: AlohaCare Medicare |
$20.64
|
| Rate for Payer: Cash Price |
$26.84
|
| Rate for Payer: Devoted Health Medicare |
$22.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.23
|
| Rate for Payer: Health Management Network Commercial |
$35.10
|
| Rate for Payer: Humana Medicare |
$20.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.64
|
| Rate for Payer: MDX Hawaii PPO |
$40.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.64
|
| Rate for Payer: University Health Alliance Commercial |
$30.10
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
IP
|
$21.57
|
|
|
Service Code
|
NDC 17478006235
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$20.92 |
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Health Management Network Commercial |
$18.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.41
|
| Rate for Payer: MDX Hawaii PPO |
$20.92
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
OP
|
$42.36
|
|
|
Service Code
|
NDC 69618006076
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.18 |
| Max. Negotiated Rate |
$41.09 |
| Rate for Payer: AlohaCare Medicaid |
$21.18
|
| Rate for Payer: AlohaCare Medicare |
$21.18
|
| Rate for Payer: Cash Price |
$27.53
|
| Rate for Payer: Devoted Health Medicare |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.24
|
| Rate for Payer: Health Management Network Commercial |
$36.01
|
| Rate for Payer: Humana Medicare |
$21.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.18
|
| Rate for Payer: MDX Hawaii PPO |
$41.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.18
|
| Rate for Payer: University Health Alliance Commercial |
$30.88
|
|
