|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS J0688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
CEFAZOLIN 500 MG SOLUTION FOR INJECTION [1448]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
CEFAZOLIN 500 MG SOLUTION FOR INJECTION [1448]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
CEFAZOLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4301445]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
CEFAZOLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4301445]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
NDC 00093413664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.70 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
NDC 65862021860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
NDC 67877054798
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
NDC 67877054798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.28 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$121.60
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.28
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
| Rate for Payer: University Health Alliance Commercial |
$93.30
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
NDC 00093413664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.02 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.02
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
| Rate for Payer: University Health Alliance Commercial |
$74.35
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
NDC 65862021860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.28 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$121.60
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.28
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
| Rate for Payer: University Health Alliance Commercial |
$93.30
|
|
|
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [39522]
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
NDC 65862021901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$201.45 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
|
|
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [39522]
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
NDC 68180072305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$201.45 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
|
|
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [39522]
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
NDC 65862021901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.87 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$225.15
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.87
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: University Health Alliance Commercial |
$172.75
|
|
|
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [39522]
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
NDC 68180072305
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.87 |
| Max. Negotiated Rate |
$229.89 |
| Rate for Payer: Cash Price |
$142.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$225.15
|
| Rate for Payer: Health Management Network Commercial |
$201.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.87
|
| Rate for Payer: MDX Hawaii PPO |
$229.89
|
| Rate for Payer: University Health Alliance Commercial |
$172.75
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687069921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 68001036206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687069911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 68001036206
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687069911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CEFDINIR 300 MG CAPSULE [22289]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687069921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CEFDINIR CAPSULES (OMNICEF) 300 MG (TAKE HOME) [4080342]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080130
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CEFDINIR CAPSULES (OMNICEF) 300 MG (TAKE HOME) [4080342]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080130
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CEFDINIR SUSPENSION (OMNICEF) 250 MG/5 ML (100 ML) (TAKE HOME) [4080341]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080129
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
