|
Lactic Acid FSI
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
8228888
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$63.00
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Cash Price |
$81.90
|
| Rate for Payer: Devoted Health Medicare |
$69.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$14.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.57
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.00
|
| Rate for Payer: University Health Alliance Commercial |
$27.60
|
|
|
Lactic Acid (iSTAT) FSI
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
13286530
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: AlohaCare Medicaid |
$77.00
|
| Rate for Payer: AlohaCare Medicare |
$77.00
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Devoted Health Medicare |
$84.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$14.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.57
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Humana Medicare |
$77.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$77.00
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.00
|
| Rate for Payer: University Health Alliance Commercial |
$27.60
|
|
|
Lactic Acid (iSTAT) FSI
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
13286530
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
|
|
Lactic Acid Reflex FSI
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
13369640
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$53.95
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
Lactic Acid Reflex FSI
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS 83605
|
| Hospital Charge Code |
13369640
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicare |
$41.50
|
| Rate for Payer: Cash Price |
$53.95
|
| Rate for Payer: Cash Price |
$53.95
|
| Rate for Payer: Devoted Health Medicare |
$45.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$14.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.57
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Humana Medicare |
$41.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.50
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.50
|
| Rate for Payer: University Health Alliance Commercial |
$27.60
|
|
|
lactobacillus rh-GG 80 mg capsule [HHSC]
|
Facility
|
OP
|
$3.21
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
2500446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: AlohaCare Medicaid |
$1.60
|
| Rate for Payer: AlohaCare Medicare |
$1.60
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Devoted Health Medicare |
$1.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.05
|
| Rate for Payer: Health Management Network Commercial |
$2.73
|
| Rate for Payer: Humana Medicare |
$1.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.60
|
| Rate for Payer: University Health Alliance Commercial |
$2.34
|
|
|
lactobacillus rh-GG 80 mg capsule [HHSC]
|
Facility
|
IP
|
$11.44
|
|
|
Service Code
|
NDC 49100040007
|
| Hospital Charge Code |
2500446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$11.10 |
| Rate for Payer: Cash Price |
$7.44
|
| Rate for Payer: Health Management Network Commercial |
$9.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.30
|
| Rate for Payer: MDX Hawaii PPO |
$11.10
|
|
|
lactobacillus rh-GG 80 mg capsule [HHSC]
|
Facility
|
OP
|
$11.44
|
|
|
Service Code
|
NDC 49100040007
|
| Hospital Charge Code |
2500446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$11.10 |
| Rate for Payer: AlohaCare Medicaid |
$5.72
|
| Rate for Payer: AlohaCare Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$7.44
|
| Rate for Payer: Devoted Health Medicare |
$6.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.87
|
| Rate for Payer: Health Management Network Commercial |
$9.72
|
| Rate for Payer: Humana Medicare |
$5.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.34
|
|
|
lactobacillus rh-GG 80 mg capsule [HHSC]
|
Facility
|
IP
|
$3.21
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
2500446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Health Management Network Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.89
|
| Rate for Payer: MDX Hawaii PPO |
$3.11
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
OP
|
$126.20
|
|
|
Service Code
|
NDC 60432003816
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.10 |
| Max. Negotiated Rate |
$122.41 |
| Rate for Payer: AlohaCare Medicaid |
$63.10
|
| Rate for Payer: AlohaCare Medicare |
$63.10
|
| Rate for Payer: Cash Price |
$82.03
|
| Rate for Payer: Devoted Health Medicare |
$69.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.89
|
| Rate for Payer: Health Management Network Commercial |
$107.27
|
| Rate for Payer: Humana Medicare |
$63.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.10
|
| Rate for Payer: MDX Hawaii PPO |
$122.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.10
|
| Rate for Payer: University Health Alliance Commercial |
$91.99
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
OP
|
$163.19
|
|
|
Service Code
|
NDC 64980059248
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.59 |
| Max. Negotiated Rate |
$158.29 |
| Rate for Payer: AlohaCare Medicaid |
$81.59
|
| Rate for Payer: AlohaCare Medicare |
$81.59
|
| Rate for Payer: Cash Price |
$106.07
|
| Rate for Payer: Devoted Health Medicare |
$89.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.03
|
| Rate for Payer: Health Management Network Commercial |
$138.71
|
| Rate for Payer: Humana Medicare |
$81.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.59
|
| Rate for Payer: MDX Hawaii PPO |
$158.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$97.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.59
|
| Rate for Payer: University Health Alliance Commercial |
$118.95
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
IP
|
$170.72
|
|
|
Service Code
|
NDC 45963043864
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.11 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Cash Price |
$110.97
|
| Rate for Payer: Health Management Network Commercial |
$145.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.65
|
| Rate for Payer: MDX Hawaii PPO |
$165.60
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
IP
|
$126.20
|
|
|
Service Code
|
NDC 60432003816
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.27 |
| Max. Negotiated Rate |
$122.41 |
| Rate for Payer: Cash Price |
$82.03
|
| Rate for Payer: Health Management Network Commercial |
$107.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.58
|
| Rate for Payer: MDX Hawaii PPO |
$122.41
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
IP
|
$163.19
|
|
|
Service Code
|
NDC 64980059248
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$138.71 |
| Max. Negotiated Rate |
$158.29 |
| Rate for Payer: Cash Price |
$106.07
|
| Rate for Payer: Health Management Network Commercial |
$138.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$146.87
|
| Rate for Payer: MDX Hawaii PPO |
$158.29
|
|
|
lactulose 10 gm/15 ml 473ml [HHSC]
|
Facility
|
OP
|
$170.72
|
|
|
Service Code
|
NDC 45963043864
|
| Hospital Charge Code |
2500447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: AlohaCare Medicaid |
$85.36
|
| Rate for Payer: AlohaCare Medicare |
$85.36
|
| Rate for Payer: Cash Price |
$110.97
|
| Rate for Payer: Devoted Health Medicare |
$93.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$162.18
|
| Rate for Payer: Health Management Network Commercial |
$145.11
|
| Rate for Payer: Humana Medicare |
$85.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.36
|
| Rate for Payer: MDX Hawaii PPO |
$165.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$102.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.36
|
| Rate for Payer: University Health Alliance Commercial |
$124.44
|
|
|
lactulose 20 gm/30 mL cup [HHSC]
|
Facility
|
IP
|
$5.25
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
2500448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Health Management Network Commercial |
$4.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.72
|
| Rate for Payer: MDX Hawaii PPO |
$5.09
|
|
|
lactulose 20 gm/30 mL cup [HHSC]
|
Facility
|
OP
|
$16.57
|
|
|
Service Code
|
NDC 50383077931
|
| Hospital Charge Code |
2500448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.29 |
| Max. Negotiated Rate |
$16.07 |
| Rate for Payer: AlohaCare Medicaid |
$8.29
|
| Rate for Payer: AlohaCare Medicare |
$8.29
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: Devoted Health Medicare |
$9.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.74
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Humana Medicare |
$8.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.29
|
| Rate for Payer: MDX Hawaii PPO |
$16.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.29
|
| Rate for Payer: University Health Alliance Commercial |
$12.08
|
|
|
lactulose 20 gm/30 mL cup [HHSC]
|
Facility
|
IP
|
$16.57
|
|
|
Service Code
|
NDC 50383077931
|
| Hospital Charge Code |
2500448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$16.07 |
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$14.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.91
|
| Rate for Payer: MDX Hawaii PPO |
$16.07
|
|
|
lactulose 20 gm/30 mL cup [HHSC]
|
Facility
|
OP
|
$5.25
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
2500448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: AlohaCare Medicaid |
$2.62
|
| Rate for Payer: AlohaCare Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Devoted Health Medicare |
$2.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.99
|
| Rate for Payer: Health Management Network Commercial |
$4.46
|
| Rate for Payer: Humana Medicare |
$2.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.62
|
| Rate for Payer: MDX Hawaii PPO |
$5.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.62
|
| Rate for Payer: University Health Alliance Commercial |
$3.83
|
|
|
lamoTRIgine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
2500449
|
|
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
|
|
|
lamoTRIgine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
2500449
|
|
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
|
|
|
lamoTRIgine 100 mg tablet [HHSC]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 51079049920
|
| Hospital Charge Code |
2500449
|
|
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
|
|
|
lamoTRIgine 100 mg tablet [HHSC]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 51079049920
|
| Hospital Charge Code |
2500449
|
|
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
|
|
|
lamoTRIgine 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084031801
|
| Hospital Charge Code |
2500450
|
|
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
|
|
|
lamoTRIgine 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084031801
|
| Hospital Charge Code |
2500450
|
|
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
|
|
