|
C8957 Prolonged IV Inf Req Pump Charge
|
Facility
|
OP
|
$588.00
|
|
|
Service Code
|
HCPCS C8957
|
| Hospital Charge Code |
8220036
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$248.77 |
| Max. Negotiated Rate |
$570.36 |
| Rate for Payer: AlohaCare Medicaid |
$294.00
|
| Rate for Payer: AlohaCare Medicare |
$294.00
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Devoted Health Medicare |
$323.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$271.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$294.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$558.60
|
| Rate for Payer: Health Management Network Commercial |
$499.80
|
| Rate for Payer: Humana Medicare |
$294.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$529.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$299.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$294.00
|
| Rate for Payer: MDX Hawaii PPO |
$570.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$294.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$294.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$248.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$294.00
|
| Rate for Payer: University Health Alliance Commercial |
$329.28
|
|
|
CAGE PLATE, 2.0MM, 2X5 HOLE
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12970968
|
|
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
|
|
|
CAGE PLATE, 2.0MM, 2X5 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12970968
|
|
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
|
|
|
CAGE PLATE, 2.4MM, 2X5 HOLE
|
Facility
|
IP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12970971
|
|
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
|
|
|
CAGE PLATE, 2.4MM, 2X5 HOLE
|
Facility
|
OP
|
$1,462.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12970971
|
|
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
|
|
|
calcium carbonate 500 mg chew tab [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904641292
|
| Hospital Charge Code |
2501139
|
|
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
|
|
|
calcium carbonate 500 mg chew tab [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904641292
|
| Hospital Charge Code |
2501139
|
|
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
|
|
|
calcium chloride 1gm/10ml syringe [HHSC]
|
Facility
|
IP
|
$59.53
|
|
|
Service Code
|
HCPCS J0618
|
| Hospital Charge Code |
2500136
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cash Price |
$46.03
|
| Rate for Payer: Health Management Network Commercial |
$50.60
|
| Rate for Payer: Health Management Network Commercial |
$60.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.74
|
| Rate for Payer: MDX Hawaii PPO |
$68.70
|
| Rate for Payer: MDX Hawaii PPO |
$57.74
|
|
|
calcium chloride 1gm/10ml syringe [HHSC]
|
Facility
|
OP
|
$70.82
|
|
|
Service Code
|
HCPCS J0618
|
| Hospital Charge Code |
2500136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.41 |
| Max. Negotiated Rate |
$68.70 |
| Rate for Payer: AlohaCare Medicaid |
$35.41
|
| Rate for Payer: AlohaCare Medicaid |
$29.77
|
| Rate for Payer: AlohaCare Medicare |
$29.77
|
| Rate for Payer: AlohaCare Medicare |
$35.41
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cash Price |
$46.03
|
| Rate for Payer: Devoted Health Medicare |
$38.95
|
| Rate for Payer: Devoted Health Medicare |
$32.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.28
|
| Rate for Payer: Health Management Network Commercial |
$60.20
|
| Rate for Payer: Health Management Network Commercial |
$50.60
|
| Rate for Payer: Humana Medicare |
$29.77
|
| Rate for Payer: Humana Medicare |
$35.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.77
|
| Rate for Payer: MDX Hawaii PPO |
$57.74
|
| Rate for Payer: MDX Hawaii PPO |
$68.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.41
|
| Rate for Payer: University Health Alliance Commercial |
$51.62
|
| Rate for Payer: University Health Alliance Commercial |
$43.39
|
|
|
Calcium FSI
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 82310
|
| Hospital Charge Code |
8117870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$50.05
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
Calcium FSI
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 82310
|
| Hospital Charge Code |
8117870
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$38.50
|
| Rate for Payer: Cash Price |
$50.05
|
| Rate for Payer: Cash Price |
$50.05
|
| Rate for Payer: Devoted Health Medicare |
$42.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.16
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$38.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.50
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.32
|
|
|
calcium gluconate 1gm/10ml vial [HHSC]
|
Facility
|
OP
|
$63.15
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
2500137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$61.26 |
| Rate for Payer: Devoted Health Medicare |
$34.73
|
| Rate for Payer: AlohaCare Medicaid |
$31.57
|
| Rate for Payer: AlohaCare Medicare |
$31.57
|
| Rate for Payer: Cash Price |
$41.05
|
| Rate for Payer: Cash Price |
$41.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.57
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.99
|
| Rate for Payer: Health Management Network Commercial |
$53.68
|
| Rate for Payer: Humana Medicare |
$31.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.57
|
| Rate for Payer: MDX Hawaii PPO |
$61.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.57
|
| Rate for Payer: University Health Alliance Commercial |
$46.03
|
|
|
calcium gluconate 1gm/10ml vial [HHSC]
|
Facility
|
IP
|
$63.15
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
2500137
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.68 |
| Max. Negotiated Rate |
$61.26 |
| Rate for Payer: Cash Price |
$41.05
|
| Rate for Payer: Health Management Network Commercial |
$53.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.84
|
| Rate for Payer: MDX Hawaii PPO |
$61.26
|
|
|
Calcium, Ionized FSI
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
10352343
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
|
|
Calcium, Ionized FSI
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
10352343
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: AlohaCare Medicaid |
$47.50
|
| Rate for Payer: AlohaCare Medicare |
$47.50
|
| Rate for Payer: Cash Price |
$61.75
|
| Rate for Payer: Cash Price |
$61.75
|
| Rate for Payer: Devoted Health Medicare |
$52.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.68
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Humana Medicare |
$47.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.50
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.32
|
|
|
Calcium iSTAT
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS 82330 QW
|
| Hospital Charge Code |
8293264
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: AlohaCare Medicaid |
$76.50
|
| Rate for Payer: AlohaCare Medicare |
$76.50
|
| Rate for Payer: Cash Price |
$99.45
|
| Rate for Payer: Cash Price |
$99.45
|
| Rate for Payer: Devoted Health Medicare |
$84.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.68
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Humana Medicare |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.50
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.32
|
|
|
Calcium iSTAT
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS 82330 QW
|
| Hospital Charge Code |
8293264
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$130.05 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: Cash Price |
$99.45
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
|
|
Calcium, Urine Timed FSI
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 86304
|
| Hospital Charge Code |
8228846
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$70.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Devoted Health Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$30.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.81
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$70.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.00
|
| Rate for Payer: University Health Alliance Commercial |
$53.78
|
|
|
Calcium, Urine Timed FSI
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 86304
|
| Hospital Charge Code |
8228846
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904323352
|
| Hospital Charge Code |
2500138
|
|
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
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
NDC 50268015015
|
| Hospital Charge Code |
2500138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$3.61 |
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Health Management Network Commercial |
$3.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.35
|
| Rate for Payer: MDX Hawaii PPO |
$3.61
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
NDC 50268015015
|
| Hospital Charge Code |
2500138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.61 |
| Rate for Payer: AlohaCare Medicaid |
$1.86
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Devoted Health Medicare |
$2.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.53
|
| Rate for Payer: Health Management Network Commercial |
$3.16
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$3.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$2.71
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 20555001700
|
| Hospital Charge Code |
2500138
|
|
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
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 20555001700
|
| Hospital Charge Code |
2500138
|
|
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
|
|
|
calcium-vit D 600mg-400 unit tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904323352
|
| Hospital Charge Code |
2500138
|
|
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
|
|
