|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
IP
|
$42.36
|
|
|
Service Code
|
NDC 69618006076
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.01 |
| Max. Negotiated Rate |
$41.09 |
| Rate for Payer: Cash Price |
$27.53
|
| Rate for Payer: Health Management Network Commercial |
$36.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.12
|
| Rate for Payer: MDX Hawaii PPO |
$41.09
|
|
|
white petr-min ophth ointment 3.5gm [HHSC]
|
Facility
|
OP
|
$72.45
|
|
|
Service Code
|
NDC 46122075737
|
| Hospital Charge Code |
2500601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.23 |
| Max. Negotiated Rate |
$70.28 |
| Rate for Payer: AlohaCare Medicaid |
$36.23
|
| Rate for Payer: AlohaCare Medicare |
$36.23
|
| Rate for Payer: Cash Price |
$47.09
|
| Rate for Payer: Devoted Health Medicare |
$39.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$68.83
|
| Rate for Payer: Health Management Network Commercial |
$61.58
|
| Rate for Payer: Humana Medicare |
$36.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.23
|
| Rate for Payer: MDX Hawaii PPO |
$70.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.23
|
| Rate for Payer: University Health Alliance Commercial |
$52.81
|
|
|
WIDE T-PLATE, 2.0MM, 10 HOLE
|
Facility
|
IP
|
$2,505.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,402.80 |
| Max. Negotiated Rate |
$2,429.85 |
| Rate for Payer: Cash Price |
$1,628.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,753.50
|
| Rate for Payer: Health Management Network Commercial |
$2,129.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,254.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,429.85
|
| Rate for Payer: University Health Alliance Commercial |
$1,402.80
|
|
|
WIDE T-PLATE, 2.0MM, 10 HOLE
|
Facility
|
OP
|
$2,505.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006748
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.50 |
| Max. Negotiated Rate |
$2,429.85 |
| Rate for Payer: AlohaCare Medicaid |
$1,252.50
|
| Rate for Payer: AlohaCare Medicare |
$1,252.50
|
| Rate for Payer: Cash Price |
$1,628.25
|
| Rate for Payer: Devoted Health Medicare |
$1,377.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,252.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,753.50
|
| Rate for Payer: Health Management Network Commercial |
$2,129.25
|
| Rate for Payer: Humana Medicare |
$1,252.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,254.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,277.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,252.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,429.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,252.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,252.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,252.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,402.80
|
|
|
WIDE T-PLATE, 2.0MM, 6 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.72 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
WIDE T-PLATE, 2.0MM, 6 HOLE
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006749
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.00 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: AlohaCare Medicaid |
$731.00
|
| Rate for Payer: AlohaCare Medicare |
$731.00
|
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Devoted Health Medicare |
$804.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$731.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Humana Medicare |
$731.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$745.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$731.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$731.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$731.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$731.00
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
WIDE T-PLATE, 2.4MM, 10 HOLE
|
Facility
|
OP
|
$2,505.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.50 |
| Max. Negotiated Rate |
$2,429.85 |
| Rate for Payer: AlohaCare Medicaid |
$1,252.50
|
| Rate for Payer: AlohaCare Medicare |
$1,252.50
|
| Rate for Payer: Cash Price |
$1,628.25
|
| Rate for Payer: Devoted Health Medicare |
$1,377.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,252.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,753.50
|
| Rate for Payer: Health Management Network Commercial |
$2,129.25
|
| Rate for Payer: Humana Medicare |
$1,252.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,254.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,277.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,252.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,429.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,252.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,252.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,252.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,402.80
|
|
|
WIDE T-PLATE, 2.4MM, 10 HOLE
|
Facility
|
IP
|
$2,505.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006752
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,402.80 |
| Max. Negotiated Rate |
$2,429.85 |
| Rate for Payer: Cash Price |
$1,628.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,753.50
|
| Rate for Payer: Health Management Network Commercial |
$2,129.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,254.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,429.85
|
| Rate for Payer: University Health Alliance Commercial |
$1,402.80
|
|
|
WIDE T-PLATE, 2.4MM, 6 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$818.72 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
WIDE T-PLATE, 2.4MM, 6 HOLE
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006750
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.00 |
| Max. Negotiated Rate |
$1,418.14 |
| Rate for Payer: AlohaCare Medicaid |
$731.00
|
| Rate for Payer: AlohaCare Medicare |
$731.00
|
| Rate for Payer: Cash Price |
$950.30
|
| Rate for Payer: Devoted Health Medicare |
$804.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$731.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,023.40
|
| Rate for Payer: Health Management Network Commercial |
$1,242.70
|
| Rate for Payer: Humana Medicare |
$731.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,315.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$745.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$731.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,418.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$731.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$731.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$731.00
|
| Rate for Payer: University Health Alliance Commercial |
$818.72
|
|
|
WIDE T-PLATE, 2.7MM, 10 HOLE
|
Facility
|
IP
|
$2,510.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,405.60 |
| Max. Negotiated Rate |
$2,434.70 |
| Rate for Payer: Cash Price |
$1,631.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,757.00
|
| Rate for Payer: Health Management Network Commercial |
$2,133.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,259.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,434.70
|
| Rate for Payer: University Health Alliance Commercial |
$1,405.60
|
|
|
WIDE T-PLATE, 2.7MM, 10 HOLE
|
Facility
|
OP
|
$2,510.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006751
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,255.00 |
| Max. Negotiated Rate |
$2,434.70 |
| Rate for Payer: AlohaCare Medicaid |
$1,255.00
|
| Rate for Payer: AlohaCare Medicare |
$1,255.00
|
| Rate for Payer: Cash Price |
$1,631.50
|
| Rate for Payer: Devoted Health Medicare |
$1,380.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,255.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,757.00
|
| Rate for Payer: Health Management Network Commercial |
$2,133.50
|
| Rate for Payer: Humana Medicare |
$1,255.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,259.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,280.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,255.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,434.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,255.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,255.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,255.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,405.60
|
|
|
WIDE T-PLATE, 2.7MM, 20 HOLE
|
Facility
|
IP
|
$3,140.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,758.40 |
| Max. Negotiated Rate |
$3,045.80 |
| Rate for Payer: Cash Price |
$2,041.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,198.00
|
| Rate for Payer: Health Management Network Commercial |
$2,669.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,826.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,045.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,758.40
|
|
|
WIDE T-PLATE, 2.7MM, 20 HOLE
|
Facility
|
OP
|
$3,140.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006753
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,570.00 |
| Max. Negotiated Rate |
$3,045.80 |
| Rate for Payer: AlohaCare Medicaid |
$1,570.00
|
| Rate for Payer: AlohaCare Medicare |
$1,570.00
|
| Rate for Payer: Cash Price |
$2,041.00
|
| Rate for Payer: Devoted Health Medicare |
$1,727.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,570.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,198.00
|
| Rate for Payer: Health Management Network Commercial |
$2,669.00
|
| Rate for Payer: Humana Medicare |
$1,570.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,826.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,601.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,570.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,045.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,570.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,570.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,570.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,758.40
|
|
|
WIDE T-PLATE, 2.7MM, 6 HOLE
|
Facility
|
OP
|
$1,883.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$941.50 |
| Max. Negotiated Rate |
$1,826.51 |
| Rate for Payer: AlohaCare Medicaid |
$941.50
|
| Rate for Payer: AlohaCare Medicare |
$941.50
|
| Rate for Payer: Cash Price |
$1,223.95
|
| Rate for Payer: Devoted Health Medicare |
$1,035.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$941.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,318.10
|
| Rate for Payer: Health Management Network Commercial |
$1,600.55
|
| Rate for Payer: Humana Medicare |
$941.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,694.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$960.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$941.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,826.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$941.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$941.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$941.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,054.48
|
|
|
WIDE T-PLATE, 2.7MM, 6 HOLE
|
Facility
|
IP
|
$1,883.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006754
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,054.48 |
| Max. Negotiated Rate |
$1,826.51 |
| Rate for Payer: Cash Price |
$1,223.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,318.10
|
| Rate for Payer: Health Management Network Commercial |
$1,600.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,694.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,826.51
|
| Rate for Payer: University Health Alliance Commercial |
$1,054.48
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
OP
|
$17.50
|
|
|
Service Code
|
NDC 12547015020
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$16.98 |
| Rate for Payer: AlohaCare Medicaid |
$8.75
|
| Rate for Payer: AlohaCare Medicare |
$8.75
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Devoted Health Medicare |
$9.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.62
|
| Rate for Payer: Health Management Network Commercial |
$14.88
|
| Rate for Payer: Humana Medicare |
$8.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.75
|
| Rate for Payer: MDX Hawaii PPO |
$16.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$12.76
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
OP
|
$21.35
|
|
|
Service Code
|
NDC 10157210301
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: AlohaCare Medicaid |
$10.68
|
| Rate for Payer: AlohaCare Medicare |
$10.68
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Devoted Health Medicare |
$11.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.28
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Humana Medicare |
$10.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.68
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.68
|
| Rate for Payer: University Health Alliance Commercial |
$15.56
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
IP
|
$515.37
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$438.06 |
| Max. Negotiated Rate |
$499.91 |
| Rate for Payer: Cash Price |
$334.99
|
| Rate for Payer: Health Management Network Commercial |
$438.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$463.83
|
| Rate for Payer: MDX Hawaii PPO |
$499.91
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
IP
|
$17.50
|
|
|
Service Code
|
NDC 12547015020
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.88 |
| Max. Negotiated Rate |
$16.98 |
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Health Management Network Commercial |
$14.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: MDX Hawaii PPO |
$16.98
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
OP
|
$515.37
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.69 |
| Max. Negotiated Rate |
$499.91 |
| Rate for Payer: AlohaCare Medicaid |
$257.69
|
| Rate for Payer: AlohaCare Medicare |
$257.69
|
| Rate for Payer: Cash Price |
$334.99
|
| Rate for Payer: Devoted Health Medicare |
$283.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$257.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$489.60
|
| Rate for Payer: Health Management Network Commercial |
$438.06
|
| Rate for Payer: Humana Medicare |
$257.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$463.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$262.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$257.69
|
| Rate for Payer: MDX Hawaii PPO |
$499.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$257.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$257.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$309.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$257.69
|
| Rate for Payer: University Health Alliance Commercial |
$375.65
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
IP
|
$21.35
|
|
|
Service Code
|
NDC 10157210301
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
IP
|
$43.48
|
|
|
Service Code
|
NDC 41388000732
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.96 |
| Max. Negotiated Rate |
$42.18 |
| Rate for Payer: Cash Price |
$28.26
|
| Rate for Payer: Health Management Network Commercial |
$36.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.13
|
| Rate for Payer: MDX Hawaii PPO |
$42.18
|
|
|
witch hazel topical 50% [HHSC]
|
Facility
|
OP
|
$43.48
|
|
|
Service Code
|
NDC 41388000732
|
| Hospital Charge Code |
2500864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$42.18 |
| Rate for Payer: AlohaCare Medicaid |
$21.74
|
| Rate for Payer: AlohaCare Medicare |
$21.74
|
| Rate for Payer: Cash Price |
$28.26
|
| Rate for Payer: Devoted Health Medicare |
$23.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.31
|
| Rate for Payer: Health Management Network Commercial |
$36.96
|
| Rate for Payer: Humana Medicare |
$21.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.74
|
| Rate for Payer: MDX Hawaii PPO |
$42.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.74
|
| Rate for Payer: University Health Alliance Commercial |
$31.69
|
|
|
Work Reconditioning Additional Hours Charge
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
HCPCS 97546 GO
|
| Hospital Charge Code |
8123851
|
|
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
|
|
