|
HMGCR Antibody IgG FSI
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
HCPCS 82397
|
| Hospital Charge Code |
12332995
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$540.29 |
| Rate for Payer: AlohaCare Medicaid |
$278.50
|
| Rate for Payer: AlohaCare Medicare |
$278.50
|
| Rate for Payer: Cash Price |
$362.05
|
| Rate for Payer: Cash Price |
$362.05
|
| Rate for Payer: Devoted Health Medicare |
$306.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.84
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$278.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.12
|
| Rate for Payer: Health Management Network Commercial |
$473.45
|
| Rate for Payer: Humana Medicare |
$278.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$501.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$284.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$278.50
|
| Rate for Payer: MDX Hawaii PPO |
$540.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$278.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$278.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$278.50
|
| Rate for Payer: University Health Alliance Commercial |
$36.52
|
|
|
Homocysteine, Total FSI
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS 83090
|
| Hospital Charge Code |
8117966
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
|
|
Homocysteine, Total FSI
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS 83090
|
| Hospital Charge Code |
8117966
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: AlohaCare Medicaid |
$132.00
|
| Rate for Payer: AlohaCare Medicare |
$132.00
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Cash Price |
$171.60
|
| Rate for Payer: Devoted Health Medicare |
$145.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.31
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$132.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.92
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Humana Medicare |
$132.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$132.00
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$132.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$132.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$132.00
|
| Rate for Payer: University Health Alliance Commercial |
$43.60
|
|
|
Hot/Cold Pack Application Charge
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS 97010 GP,CQ
|
| Hospital Charge Code |
8123894
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.08 |
| 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 Medicare |
$47.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.25
|
| 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 |
$10.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.50
|
| Rate for Payer: University Health Alliance Commercial |
$53.20
|
|
|
Hot/Cold Pack Application Charge
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS 97010 GP,CQ
|
| Hospital Charge Code |
8123894
|
|
Hospital Revenue Code
|
430
|
| 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
|
|
|
.HPV Genotype 16, 18/45 FSI
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS 87625
|
| Hospital Charge Code |
8727819
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: AlohaCare Medicaid |
$138.00
|
| Rate for Payer: AlohaCare Medicare |
$138.00
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Devoted Health Medicare |
$151.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$138.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.55
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Humana Medicare |
$138.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$140.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$138.00
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$138.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$138.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$138.00
|
| Rate for Payer: University Health Alliance Commercial |
$88.36
|
|
|
.HPV Genotype 16, 18/45 FSI
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS 87625
|
| Hospital Charge Code |
8727819
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$234.60 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
|
|
HPV High Risk, Cervical FSI
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS 87624
|
| Hospital Charge Code |
11545252
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: AlohaCare Medicaid |
$196.00
|
| Rate for Payer: AlohaCare Medicare |
$196.00
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Devoted Health Medicare |
$215.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$196.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Humana Medicare |
$196.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$196.00
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$196.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$196.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$196.00
|
| Rate for Payer: University Health Alliance Commercial |
$88.36
|
|
|
HPV High Risk, Cervical FSI
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
HCPCS 87624
|
| Hospital Charge Code |
11545252
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
|
|
HPV†High†Risk†Screen, Cervical FSI
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS 87624
|
| Hospital Charge Code |
8727825
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$28.68 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: AlohaCare Medicaid |
$196.00
|
| Rate for Payer: AlohaCare Medicare |
$196.00
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Devoted Health Medicare |
$215.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$196.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Humana Medicare |
$196.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$196.00
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$196.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$196.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$196.00
|
| Rate for Payer: University Health Alliance Commercial |
$88.36
|
|
|
HPV†High†Risk†Screen, Cervical FSI
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
HCPCS 87624
|
| Hospital Charge Code |
8727825
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
|
|
HSV Subtype by PCR FSI
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
HCPCS 87529
|
| Hospital Charge Code |
8191170
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
|
|
HSV Subtype by PCR FSI
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS 87529
|
| Hospital Charge Code |
8191170
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: AlohaCare Medicaid |
$196.00
|
| Rate for Payer: AlohaCare Medicare |
$196.00
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Cash Price |
$254.80
|
| Rate for Payer: Devoted Health Medicare |
$215.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$46.44
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$196.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$48.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Humana Medicare |
$196.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$196.00
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$196.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$196.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$196.00
|
| Rate for Payer: University Health Alliance Commercial |
$90.72
|
|
|
Human Growth Hormone FSI
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
11447067
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$162.35 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: Cash Price |
$124.15
|
| Rate for Payer: Health Management Network Commercial |
$162.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.90
|
| Rate for Payer: MDX Hawaii PPO |
$185.27
|
|
|
Human Growth Hormone FSI
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
HCPCS 83003
|
| Hospital Charge Code |
11447067
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.67 |
| Max. Negotiated Rate |
$185.27 |
| Rate for Payer: AlohaCare Medicaid |
$95.50
|
| Rate for Payer: AlohaCare Medicare |
$95.50
|
| Rate for Payer: Cash Price |
$124.15
|
| Rate for Payer: Cash Price |
$124.15
|
| Rate for Payer: Devoted Health Medicare |
$105.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.67
|
| Rate for Payer: Health Management Network Commercial |
$162.35
|
| Rate for Payer: Humana Medicare |
$95.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$97.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.50
|
| Rate for Payer: MDX Hawaii PPO |
$185.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.50
|
| Rate for Payer: University Health Alliance Commercial |
$43.09
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687083301
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904644261
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904644261
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687083301
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62584073401
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62584073401
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
