|
AXILLARY LYMPHADENECTOMY; COMPLETE
|
Facility
|
OP
|
$13,778.00
|
|
|
Service Code
|
CPT 38745
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$521.33 |
| Max. Negotiated Rate |
$13,778.00 |
| Rate for Payer: AlohaCare Medicaid |
$7,141.85
|
| Rate for Payer: AlohaCare Medicare |
$7,141.85
|
| Rate for Payer: Devoted Health Medicare |
$7,856.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,149.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,778.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,141.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,294.85
|
| Rate for Payer: Humana Medicare |
$7,141.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,141.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,856.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,141.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,141.85
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
AZACITIDINE 100 MG/4ML SUBQ CHEMO IJ (WET SUSR VIAL) [4307842001]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
|
|
AZACITIDINE 100 MG/4ML SUBQ CHEMO IJ (WET SUSR VIAL) [4307842001]
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$880.65
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$584.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$472.77
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$556.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.80
|
| Rate for Payer: University Health Alliance Commercial |
$675.69
|
| Rate for Payer: University Health Alliance Commercial |
$78.72
|
| Rate for Payer: University Health Alliance Commercial |
$82.37
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$787.95 |
| Max. Negotiated Rate |
$899.19 |
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$880.65
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$584.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$472.77
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$556.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.80
|
| Rate for Payer: University Health Alliance Commercial |
$78.72
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
| Rate for Payer: University Health Alliance Commercial |
$675.69
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J7500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J7500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 00093202723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 00093202723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 00069314019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 59762314001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 00093202631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 00093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 00069314019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 59762314001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687074201
|
|
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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 60687028265
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687028265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687074211
|
|
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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687074201
|
|
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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687074211
|
|
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
|
|
|
AZITHROMYCIN 500 MG/5ML IV (WET SOLR VIAL) [43021063]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
AZITHROMYCIN 500 MG/5ML IV (WET SOLR VIAL) [43021063]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
AZITHROMYCIN 500 MG IN 250 ML NS ADD-A-VIAL (SIMPLE) [4080012]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
AZITHROMYCIN 500 MG IN 250 ML NS ADD-A-VIAL (SIMPLE) [4080012]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
