|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 50580045811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 50580045811
|
|
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
|
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00536132710
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904677361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00536132710
|
|
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
|
|
|
ACETAMINOPHEN 325 MG TABLET [101]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904677361
|
|
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
|
|
|
ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [205406]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0136
|
|
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
|
|
|
ACETAMINOPHEN 500 MG/50 ML (10 MG/ML) INTRAVENOUS SOLUTION [205406]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| 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 |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| 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
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 45802073000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 45802073030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 45802073033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802073030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 45802073033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802073000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ACETAMINOPHEN SUPPOSITORIES (TYLENOL) 120 MG (TAKE HOME) [4080327]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080115
|
|
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
|
|
|
ACETAMINOPHEN SUPPOSITORIES (TYLENOL) 120 MG (TAKE HOME) [4080327]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080115
|
|
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
|
|
|
ACETAMINOPHEN SUSPENSION (TYLENOL) 160 MG/5 ML (120 ML) (TAKE HOME) [4080329]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080117
|
|
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
|
|
|
ACETAMINOPHEN SUSPENSION (TYLENOL) 160 MG/5 ML (120 ML) (TAKE HOME) [4080329]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080117
|
|
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
|
|
|
ACETAMINOPHEN TABLETS (TYLENOL) 325 MG (TAKE HOME) [4080328]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080116
|
|
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
|
|
|
ACETAMINOPHEN TABLETS (TYLENOL) 325 MG (TAKE HOME) [4080328]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080116
|
|
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
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 50268005411
|
|
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
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687061901
|
|
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
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 50268005415
|
|
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
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687061911
|
|
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
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687061901
|
|
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
|
|
