|
L3913 - Gel Shell Roylan Thumb
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS L3913
|
| Hospital Charge Code |
8409609
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$66.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.10
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: University Health Alliance Commercial |
$57.68
|
|
|
L3919 - Roylan Gel Shell Thumb Md
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS L3919
|
| Hospital Charge Code |
8409610
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicare |
$53.00
|
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Devoted Health Medicare |
$58.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.20
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Humana Medicare |
$53.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.00
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$116.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.00
|
| Rate for Payer: University Health Alliance Commercial |
$59.36
|
|
|
L3919 - Roylan Gel Shell Thumb Md
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
HCPCS L3919
|
| Hospital Charge Code |
8409610
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$59.36 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.20
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: University Health Alliance Commercial |
$59.36
|
|
|
L3923 - Cushion Fngr Contracture
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS L3923
|
| Hospital Charge Code |
8409601
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: University Health Alliance Commercial |
$13.44
|
|
|
L3923 - Cushion Fngr Contracture
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS L3923
|
| Hospital Charge Code |
8409601
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicare |
$12.00
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$13.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Humana Medicare |
$12.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.00
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.00
|
| Rate for Payer: University Health Alliance Commercial |
$13.44
|
|
|
L3933 - HFO Palm Grip
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS L3933
|
| Hospital Charge Code |
8409603
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.50
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.50
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: University Health Alliance Commercial |
$19.60
|
|
|
L3933 - HFO Palm Grip
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS L3933
|
| Hospital Charge Code |
8409603
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$91.55 |
| Rate for Payer: AlohaCare Medicaid |
$17.50
|
| Rate for Payer: AlohaCare Medicare |
$17.50
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: Devoted Health Medicare |
$19.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.50
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Humana Medicare |
$17.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.50
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.50
|
| Rate for Payer: University Health Alliance Commercial |
$19.60
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 00409012525
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$25.63 |
| Rate for Payer: Cash Price |
$17.17
|
| Rate for Payer: Health Management Network Commercial |
$22.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.78
|
| Rate for Payer: MDX Hawaii PPO |
$25.63
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 00409012525
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$25.63 |
| Rate for Payer: AlohaCare Medicaid |
$13.21
|
| Rate for Payer: AlohaCare Medicare |
$13.21
|
| Rate for Payer: Cash Price |
$17.17
|
| Rate for Payer: Devoted Health Medicare |
$14.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.10
|
| Rate for Payer: Health Management Network Commercial |
$22.46
|
| Rate for Payer: Humana Medicare |
$13.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.21
|
| Rate for Payer: MDX Hawaii PPO |
$25.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.21
|
| Rate for Payer: University Health Alliance Commercial |
$19.26
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$22.35
|
|
|
Service Code
|
NDC 00409226725
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$21.68 |
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Health Management Network Commercial |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.11
|
| Rate for Payer: MDX Hawaii PPO |
$21.68
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$56.43
|
|
|
Service Code
|
NDC 72266010201
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$54.74 |
| Rate for Payer: AlohaCare Medicaid |
$28.21
|
| Rate for Payer: AlohaCare Medicare |
$28.21
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Devoted Health Medicare |
$31.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.61
|
| Rate for Payer: Health Management Network Commercial |
$47.97
|
| Rate for Payer: Humana Medicare |
$28.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.21
|
| Rate for Payer: MDX Hawaii PPO |
$54.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.21
|
| Rate for Payer: University Health Alliance Commercial |
$41.13
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$56.43
|
|
|
Service Code
|
NDC 72266010201
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.97 |
| Max. Negotiated Rate |
$54.74 |
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Health Management Network Commercial |
$47.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.79
|
| Rate for Payer: MDX Hawaii PPO |
$54.74
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 00143962201
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$44.81 |
| Rate for Payer: AlohaCare Medicaid |
$23.10
|
| Rate for Payer: AlohaCare Medicare |
$23.10
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Devoted Health Medicare |
$25.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.89
|
| Rate for Payer: Health Management Network Commercial |
$39.27
|
| Rate for Payer: Humana Medicare |
$23.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.10
|
| Rate for Payer: MDX Hawaii PPO |
$44.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.10
|
| Rate for Payer: University Health Alliance Commercial |
$33.68
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 00143962201
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$44.81 |
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Health Management Network Commercial |
$39.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: MDX Hawaii PPO |
$44.81
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$75.62
|
|
|
Service Code
|
NDC 47781058629
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.81 |
| Max. Negotiated Rate |
$73.35 |
| Rate for Payer: AlohaCare Medicaid |
$37.81
|
| Rate for Payer: AlohaCare Medicare |
$37.81
|
| Rate for Payer: Cash Price |
$49.15
|
| Rate for Payer: Devoted Health Medicare |
$41.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.84
|
| Rate for Payer: Health Management Network Commercial |
$64.28
|
| Rate for Payer: Humana Medicare |
$37.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.81
|
| Rate for Payer: MDX Hawaii PPO |
$73.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.81
|
| Rate for Payer: University Health Alliance Commercial |
$55.12
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$24.02
|
|
|
Service Code
|
NDC 25021031720
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$20.68
|
|
|
Service Code
|
NDC 00409226720
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$20.06 |
| Rate for Payer: Cash Price |
$13.44
|
| Rate for Payer: Health Management Network Commercial |
$17.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.61
|
| Rate for Payer: MDX Hawaii PPO |
$20.06
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$148.78
|
|
|
Service Code
|
NDC 17478042020
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.46 |
| Max. Negotiated Rate |
$144.32 |
| Rate for Payer: Cash Price |
$96.71
|
| Rate for Payer: Health Management Network Commercial |
$126.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.90
|
| Rate for Payer: MDX Hawaii PPO |
$144.32
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$75.62
|
|
|
Service Code
|
NDC 47781058629
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.28 |
| Max. Negotiated Rate |
$73.35 |
| Rate for Payer: Cash Price |
$49.15
|
| Rate for Payer: Health Management Network Commercial |
$64.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.06
|
| Rate for Payer: MDX Hawaii PPO |
$73.35
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$148.78
|
|
|
Service Code
|
NDC 17478042020
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.39 |
| Max. Negotiated Rate |
$144.32 |
| Rate for Payer: AlohaCare Medicaid |
$74.39
|
| Rate for Payer: AlohaCare Medicare |
$74.39
|
| Rate for Payer: Cash Price |
$96.71
|
| Rate for Payer: Devoted Health Medicare |
$81.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.34
|
| Rate for Payer: Health Management Network Commercial |
$126.46
|
| Rate for Payer: Humana Medicare |
$74.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.39
|
| Rate for Payer: MDX Hawaii PPO |
$144.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.39
|
| Rate for Payer: University Health Alliance Commercial |
$108.45
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$24.02
|
|
|
Service Code
|
NDC 25021031720
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: AlohaCare Medicaid |
$12.01
|
| Rate for Payer: AlohaCare Medicare |
$12.01
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Devoted Health Medicare |
$13.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.82
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Humana Medicare |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.01
|
| Rate for Payer: University Health Alliance Commercial |
$17.51
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
IP
|
$14.12
|
|
|
Service Code
|
NDC 36000032202
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$13.70 |
| Rate for Payer: Cash Price |
$9.18
|
| Rate for Payer: Health Management Network Commercial |
$12.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.71
|
| Rate for Payer: MDX Hawaii PPO |
$13.70
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$14.12
|
|
|
Service Code
|
NDC 36000032202
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$13.70 |
| Rate for Payer: AlohaCare Medicaid |
$7.06
|
| Rate for Payer: AlohaCare Medicare |
$7.06
|
| Rate for Payer: Cash Price |
$9.18
|
| Rate for Payer: Devoted Health Medicare |
$7.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.41
|
| Rate for Payer: Health Management Network Commercial |
$12.00
|
| Rate for Payer: Humana Medicare |
$7.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.06
|
| Rate for Payer: MDX Hawaii PPO |
$13.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.06
|
| Rate for Payer: University Health Alliance Commercial |
$10.29
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$22.35
|
|
|
Service Code
|
NDC 00409226725
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$21.68 |
| Rate for Payer: AlohaCare Medicaid |
$11.18
|
| Rate for Payer: AlohaCare Medicare |
$11.18
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Devoted Health Medicare |
$12.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.23
|
| Rate for Payer: Health Management Network Commercial |
$19.00
|
| Rate for Payer: Humana Medicare |
$11.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.18
|
| Rate for Payer: MDX Hawaii PPO |
$21.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.18
|
| Rate for Payer: University Health Alliance Commercial |
$16.29
|
|
|
labetalol 100 mg/20ml vial [HHSC]
|
Facility
|
OP
|
$20.68
|
|
|
Service Code
|
NDC 00409226720
|
| Hospital Charge Code |
2500444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$20.06 |
| Rate for Payer: AlohaCare Medicaid |
$10.34
|
| Rate for Payer: AlohaCare Medicare |
$10.34
|
| Rate for Payer: Cash Price |
$13.44
|
| Rate for Payer: Devoted Health Medicare |
$11.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.65
|
| Rate for Payer: Health Management Network Commercial |
$17.58
|
| Rate for Payer: Humana Medicare |
$10.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.34
|
| Rate for Payer: MDX Hawaii PPO |
$20.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.34
|
| Rate for Payer: University Health Alliance Commercial |
$15.07
|
|
