|
AMINO ACID 5 % NO.6 IN DEXTROSE 20 % INTRAVENOUS SOLUTION [25753]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 00338110104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$291.55 |
| Max. Negotiated Rate |
$332.71 |
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Health Management Network Commercial |
$291.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$308.70
|
| Rate for Payer: MDX Hawaii PPO |
$332.71
|
|
|
AMINO ACID 5 % NO.6 IN DEXTROSE 20 % INTRAVENOUS SOLUTION [25753]
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 00338113803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$183.33 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$170.10
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
|
|
AMINOCAPROIC ACID 250 MG/ML INFUSION (UNDILUTED) [400710]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409434673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J0281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
AMINOCAPROIC ACID 250 MG/ML IV BOLUS (UNDILUTED) [400670]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00409434673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J0280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: AlohaCare Medicare |
$63.08
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Devoted Health Medicare |
$69.72
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Humana Medicare |
$63.08
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J0280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV [110257]
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 00245014789
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicare |
$18.24
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Humana Medicare |
$18.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.24
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.24
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687043701
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687043701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 00245014701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687043711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 00245014789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687043711
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 00245014701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicare |
$18.24
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Devoted Health Medicare |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Humana Medicare |
$18.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.24
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.24
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV [110258]
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [93084]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0282
|
|
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 |
$11.40
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
AMIODARONE 900 MG IN 500 ML D5W (1.8 MG/ML) INFUSION (SIMPLE) [4080501]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 00004080059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.80 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
|
|
AMIODARONE 900 MG IN 500 ML D5W (1.8 MG/ML) INFUSION (SIMPLE) [4080501]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 00004080034
|
|
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: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 16729017101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 29300041901
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 16729017101
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
AMITRIPTYLINE 10 MG TABLET [432]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 29300041901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
AMITRIPTYLINE 25 MG TABLET [435]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687043301
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
