|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$7.80
|
| 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 |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
AZITHROMYCIN SUSPENSION (ZITHROMAX) 200 MG/5 ML (30 ML) (TAKE HOME) [4080338]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080126
|
|
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
|
|
|
AZITHROMYCIN SUSPENSION (ZITHROMAX) 200 MG/5 ML (30 ML) (TAKE HOME) [4080338]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080126
|
|
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
|
|
|
AZITHROMYCIN TABLETS (ZITHROMAX) 250 MG (TAKE HOME) [4080339]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080127
|
|
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
|
|
|
AZITHROMYCIN TABLETS (ZITHROMAX) 250 MG (TAKE HOME) [4080339]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080127
|
|
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
|
|
|
AZTREONAM 1 G/3ML IJ (WET SOLR VIAL) [4309185]
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
AZTREONAM 1 G/3ML IJ (WET SOLR VIAL) [4309185]
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.40
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
| Rate for Payer: University Health Alliance Commercial |
$79.45
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
|
|
AZTREONAM 1 GRAM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080115]
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
NDC 00004080102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.05 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
|
|
AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
AZTREONAM 2 G/6ML IJ (WET SOLR VIAL) [4309186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
NDC 63323040201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 G/6ML IJ (WET SOLR VIAL) [4309186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
NDC 63323040220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.10
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.38
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.80
|
| Rate for Payer: University Health Alliance Commercial |
$100.59
|
|
|
AZURE XT DR AZUREXTDRMRIMEEM
|
Facility
|
OP
|
$13,452.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,860.52 |
| Max. Negotiated Rate |
$13,048.44 |
| Rate for Payer: Cash Price |
$8,071.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,416.40
|
| Rate for Payer: Health Management Network Commercial |
$11,434.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,474.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,860.52
|
| Rate for Payer: MDX Hawaii PPO |
$13,048.44
|
| Rate for Payer: University Health Alliance Commercial |
$7,533.12
|
|
|
AZURE XT DR AZUREXTDRMRIMEEM
|
Facility
|
IP
|
$13,452.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$7,533.12 |
| Max. Negotiated Rate |
$13,048.44 |
| Rate for Payer: Cash Price |
$8,071.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,416.40
|
| Rate for Payer: Health Management Network Commercial |
$11,434.20
|
| Rate for Payer: MDX Hawaii PPO |
$13,048.44
|
| Rate for Payer: University Health Alliance Commercial |
$7,533.12
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
NDC 00574402235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.84 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$178.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: University Health Alliance Commercial |
$207.01
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
NDC 00574402235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.40 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68001047746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68001047747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 45802006001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68001047747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68001047746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 45802006001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802006070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
