|
CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
HCPCS 94781
|
| Hospital Charge Code |
8243381
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$24.65 |
| Rate for Payer: AlohaCare Medicaid |
$8.14
|
| Rate for Payer: AlohaCare Medicare |
$7.01
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Devoted Health Medicare |
$7.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.14
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.01
|
| Rate for Payer: University Health Alliance Commercial |
$9.92
|
|
|
Car Seat Oximetry Challenge Follow Up
|
Professional
|
Both
|
$46.00
|
|
|
Service Code
|
HCPCS 94781
|
| Hospital Charge Code |
7548540
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$39.10 |
| Rate for Payer: AlohaCare Medicaid |
$8.14
|
| Rate for Payer: AlohaCare Medicare |
$7.01
|
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Devoted Health Medicare |
$7.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.14
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.01
|
| Rate for Payer: University Health Alliance Commercial |
$9.92
|
|
|
Car Seat Oximetry Challenge Follow Up
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 94781
|
| Hospital Charge Code |
7548540
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
|
|
Car Seat Oximetry Challenge Follow Up
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 94781
|
| Hospital Charge Code |
7548540
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: AlohaCare Medicaid |
$62.50
|
| Rate for Payer: AlohaCare Medicare |
$62.50
|
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Cash Price |
$81.25
|
| Rate for Payer: Devoted Health Medicare |
$68.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.75
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Humana Medicare |
$62.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.50
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.50
|
| Rate for Payer: University Health Alliance Commercial |
$70.00
|
|
|
Car Seat Oximetry Challenge Initial
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS 94780
|
| Hospital Charge Code |
1666889
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$20.41 |
| Max. Negotiated Rate |
$117.30 |
| Rate for Payer: AlohaCare Medicaid |
$23.42
|
| Rate for Payer: AlohaCare Medicare |
$20.41
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Cash Price |
$89.70
|
| Rate for Payer: Devoted Health Medicare |
$22.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.42
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$28.80
|
|
|
Car Seat Oximetry Challenge Initial
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
HCPCS 94780
|
| Hospital Charge Code |
1666889
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$209.52 |
| Rate for Payer: AlohaCare Medicaid |
$108.00
|
| Rate for Payer: AlohaCare Medicare |
$108.00
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Devoted Health Medicare |
$118.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$47.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$205.20
|
| Rate for Payer: Health Management Network Commercial |
$183.60
|
| Rate for Payer: Humana Medicare |
$108.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$194.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$110.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$209.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.00
|
| Rate for Payer: University Health Alliance Commercial |
$120.96
|
|
|
Car Seat Oximetry Challenge Initial
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
HCPCS 94780
|
| Hospital Charge Code |
1666889
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$183.60 |
| Max. Negotiated Rate |
$209.52 |
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Health Management Network Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$194.40
|
| Rate for Payer: MDX Hawaii PPO |
$209.52
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
OP
|
$11.68
|
|
|
Service Code
|
NDC 00904630261
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: AlohaCare Medicaid |
$5.84
|
| Rate for Payer: AlohaCare Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.10
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Humana Medicare |
$5.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.84
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
OP
|
$10.84
|
|
|
Service Code
|
NDC 68084086501
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.42 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: AlohaCare Medicaid |
$5.42
|
| Rate for Payer: AlohaCare Medicare |
$5.42
|
| Rate for Payer: Cash Price |
$7.05
|
| Rate for Payer: Devoted Health Medicare |
$5.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.30
|
| Rate for Payer: Health Management Network Commercial |
$9.21
|
| Rate for Payer: Humana Medicare |
$5.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.42
|
| Rate for Payer: MDX Hawaii PPO |
$10.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.42
|
| Rate for Payer: University Health Alliance Commercial |
$7.90
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904730761
|
| Hospital Charge Code |
2500147
|
|
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
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
IP
|
$11.87
|
|
|
Service Code
|
NDC 51079093120
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Health Management Network Commercial |
$10.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.68
|
| Rate for Payer: MDX Hawaii PPO |
$11.51
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
IP
|
$11.68
|
|
|
Service Code
|
NDC 00904630261
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904730761
|
| Hospital Charge Code |
2500147
|
|
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
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
IP
|
$10.84
|
|
|
Service Code
|
NDC 68084086501
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.21 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Cash Price |
$7.05
|
| Rate for Payer: Health Management Network Commercial |
$9.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.76
|
| Rate for Payer: MDX Hawaii PPO |
$10.51
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
OP
|
$11.88
|
|
|
Service Code
|
NDC 68001015100
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: AlohaCare Medicaid |
$5.94
|
| Rate for Payer: AlohaCare Medicare |
$5.94
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Devoted Health Medicare |
$6.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.29
|
| Rate for Payer: Health Management Network Commercial |
$10.10
|
| Rate for Payer: Humana Medicare |
$5.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.94
|
| Rate for Payer: MDX Hawaii PPO |
$11.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.94
|
| Rate for Payer: University Health Alliance Commercial |
$8.66
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
IP
|
$11.88
|
|
|
Service Code
|
NDC 68001015100
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Health Management Network Commercial |
$10.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.69
|
| Rate for Payer: MDX Hawaii PPO |
$11.52
|
|
|
carvedilol 12.5 mg tablet [HHSC]
|
Facility
|
OP
|
$11.87
|
|
|
Service Code
|
NDC 51079093120
|
| Hospital Charge Code |
2500147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: AlohaCare Medicaid |
$5.93
|
| Rate for Payer: AlohaCare Medicare |
$5.93
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Devoted Health Medicare |
$6.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$10.09
|
| Rate for Payer: Humana Medicare |
$5.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.93
|
| Rate for Payer: MDX Hawaii PPO |
$11.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.93
|
| Rate for Payer: University Health Alliance Commercial |
$8.65
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
OP
|
$11.88
|
|
|
Service Code
|
NDC 68001015300
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: AlohaCare Medicaid |
$5.94
|
| Rate for Payer: AlohaCare Medicare |
$5.94
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Devoted Health Medicare |
$6.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.29
|
| Rate for Payer: Health Management Network Commercial |
$10.10
|
| Rate for Payer: Humana Medicare |
$5.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.94
|
| Rate for Payer: MDX Hawaii PPO |
$11.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.94
|
| Rate for Payer: University Health Alliance Commercial |
$8.66
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
IP
|
$11.88
|
|
|
Service Code
|
NDC 68001015300
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$11.52 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Health Management Network Commercial |
$10.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.69
|
| Rate for Payer: MDX Hawaii PPO |
$11.52
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
OP
|
$11.87
|
|
|
Service Code
|
NDC 51079077120
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: AlohaCare Medicaid |
$5.93
|
| Rate for Payer: AlohaCare Medicare |
$5.93
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Devoted Health Medicare |
$6.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$10.09
|
| Rate for Payer: Humana Medicare |
$5.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.93
|
| Rate for Payer: MDX Hawaii PPO |
$11.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.93
|
| Rate for Payer: University Health Alliance Commercial |
$8.65
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
IP
|
$11.87
|
|
|
Service Code
|
NDC 51079077120
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Health Management Network Commercial |
$10.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.68
|
| Rate for Payer: MDX Hawaii PPO |
$11.51
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
IP
|
$10.84
|
|
|
Service Code
|
NDC 68084084301
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.21 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Cash Price |
$7.05
|
| Rate for Payer: Health Management Network Commercial |
$9.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.76
|
| Rate for Payer: MDX Hawaii PPO |
$10.51
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
IP
|
$11.68
|
|
|
Service Code
|
NDC 00904630061
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
OP
|
$11.68
|
|
|
Service Code
|
NDC 00904630061
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: AlohaCare Medicaid |
$5.84
|
| Rate for Payer: AlohaCare Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.10
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Humana Medicare |
$5.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.84
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
|
|
carvedilol 3.125 mg tablet [HHSC]
|
Facility
|
OP
|
$10.84
|
|
|
Service Code
|
NDC 68084084301
|
| Hospital Charge Code |
2500149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.42 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: AlohaCare Medicaid |
$5.42
|
| Rate for Payer: AlohaCare Medicare |
$5.42
|
| Rate for Payer: Cash Price |
$7.05
|
| Rate for Payer: Devoted Health Medicare |
$5.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.30
|
| Rate for Payer: Health Management Network Commercial |
$9.21
|
| Rate for Payer: Humana Medicare |
$5.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.42
|
| Rate for Payer: MDX Hawaii PPO |
$10.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.42
|
| Rate for Payer: University Health Alliance Commercial |
$7.90
|
|
