|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 50268008811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: AlohaCare Medicaid |
$37.50
|
| Rate for Payer: AlohaCare Medicare |
$57.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.25
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Humana Medicare |
$57.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.00
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.00
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 50268008815
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: AlohaCare Medicaid |
$37.50
|
| Rate for Payer: AlohaCare Medicare |
$57.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.25
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Humana Medicare |
$57.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.00
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.00
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
NDC 67877043103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.85 |
| Max. Negotiated Rate |
$78.57 |
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Health Management Network Commercial |
$68.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.90
|
| Rate for Payer: MDX Hawaii PPO |
$78.57
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 50268008815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 50268008811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
|
|
ARIPIPRAZOLE 5 MG TABLET [36438]
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
NDC 67877043103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$78.57 |
| Rate for Payer: AlohaCare Medicaid |
$40.50
|
| Rate for Payer: AlohaCare Medicare |
$61.56
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Devoted Health Medicare |
$68.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.95
|
| Rate for Payer: Health Management Network Commercial |
$68.85
|
| Rate for Payer: Humana Medicare |
$61.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.56
|
| Rate for Payer: MDX Hawaii PPO |
$78.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.56
|
| Rate for Payer: University Health Alliance Commercial |
$59.04
|
|
|
ARM SLEEVE SHLDR SUS AR-1651
|
Facility
|
OP
|
$593.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$296.50 |
| Max. Negotiated Rate |
$575.21 |
| Rate for Payer: AlohaCare Medicaid |
$296.50
|
| Rate for Payer: AlohaCare Medicare |
$450.68
|
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Devoted Health Medicare |
$498.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$450.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$563.35
|
| Rate for Payer: Health Management Network Commercial |
$504.05
|
| Rate for Payer: Humana Medicare |
$450.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$533.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$302.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$450.68
|
| Rate for Payer: MDX Hawaii PPO |
$575.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$450.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$450.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$450.68
|
| Rate for Payer: University Health Alliance Commercial |
$432.24
|
|
|
ARM SLEEVE SHLDR SUS AR-1651
|
Facility
|
IP
|
$593.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$504.05 |
| Max. Negotiated Rate |
$575.21 |
| Rate for Payer: Cash Price |
$355.80
|
| Rate for Payer: Health Management Network Commercial |
$504.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$533.70
|
| Rate for Payer: MDX Hawaii PPO |
$575.21
|
|
|
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]
|
Facility
|
OP
|
$1,426.00
|
|
|
Service Code
|
HCPCS J9017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$1,383.22 |
| Rate for Payer: AlohaCare Medicaid |
$713.00
|
| Rate for Payer: AlohaCare Medicaid |
$460.00
|
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$342.00
|
| Rate for Payer: AlohaCare Medicare |
$1,083.76
|
| Rate for Payer: AlohaCare Medicare |
$699.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$855.60
|
| Rate for Payer: Cash Price |
$855.60
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Devoted Health Medicare |
$1,197.84
|
| Rate for Payer: Devoted Health Medicare |
$772.80
|
| Rate for Payer: Devoted Health Medicare |
$378.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,083.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$699.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$342.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,354.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$874.00
|
| Rate for Payer: Health Management Network Commercial |
$782.00
|
| Rate for Payer: Health Management Network Commercial |
$1,212.10
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$1,083.76
|
| Rate for Payer: Humana Medicare |
$342.00
|
| Rate for Payer: Humana Medicare |
$699.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,283.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$828.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$469.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$727.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,083.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$699.20
|
| Rate for Payer: MDX Hawaii PPO |
$892.40
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,383.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,083.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$699.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,083.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$699.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$270.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$855.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$552.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$342.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,083.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$699.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,039.41
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
| Rate for Payer: University Health Alliance Commercial |
$670.59
|
|
|
ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION [29071]
|
Facility
|
IP
|
$920.00
|
|
|
Service Code
|
HCPCS J9017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$782.00 |
| Max. Negotiated Rate |
$892.40 |
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$855.60
|
| Rate for Payer: Health Management Network Commercial |
$1,212.10
|
| Rate for Payer: Health Management Network Commercial |
$782.00
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$828.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,283.40
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,383.22
|
| Rate for Payer: MDX Hawaii PPO |
$892.40
|
|
|
ART COMP OVOMOT 8HMC2-5046-A
|
Facility
|
OP
|
$15,252.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,626.00 |
| Max. Negotiated Rate |
$14,794.44 |
| Rate for Payer: AlohaCare Medicaid |
$7,626.00
|
| Rate for Payer: AlohaCare Medicare |
$11,591.52
|
| Rate for Payer: Cash Price |
$9,151.20
|
| Rate for Payer: Devoted Health Medicare |
$12,811.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,591.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,676.40
|
| Rate for Payer: Health Management Network Commercial |
$12,964.20
|
| Rate for Payer: Humana Medicare |
$11,591.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,726.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,778.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,591.52
|
| Rate for Payer: MDX Hawaii PPO |
$14,794.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,591.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,591.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,591.52
|
| Rate for Payer: University Health Alliance Commercial |
$8,541.12
|
|
|
ART COMP OVOMOT 8HMC2-5046-A
|
Facility
|
IP
|
$15,252.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,541.12 |
| Max. Negotiated Rate |
$14,794.44 |
| Rate for Payer: Cash Price |
$9,151.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,676.40
|
| Rate for Payer: Health Management Network Commercial |
$12,964.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,726.80
|
| Rate for Payer: MDX Hawaii PPO |
$14,794.44
|
| Rate for Payer: University Health Alliance Commercial |
$8,541.12
|
|
|
ARTERY SHUNT KIT 8888577775
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
|
|
ARTERY SHUNT KIT 8888577775
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS C1889
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: AlohaCare Medicaid |
$78.00
|
| Rate for Payer: AlohaCare Medicare |
$118.56
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$131.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.20
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Humana Medicare |
$118.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.56
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.56
|
| Rate for Payer: University Health Alliance Commercial |
$113.71
|
|
|
ARTHROSCOPY TUBING #AR-6410
|
Facility
|
IP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
|
|
ARTHROSCOPY TUBING #AR-6410
|
Facility
|
OP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: AlohaCare Medicaid |
$120.00
|
| Rate for Payer: AlohaCare Medicare |
$182.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Devoted Health Medicare |
$201.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$182.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Humana Medicare |
$182.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$182.40
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$182.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$182.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$182.40
|
| Rate for Payer: University Health Alliance Commercial |
$174.94
|
|
|
ARTICULAR GLENOID G203-2015-W
|
Facility
|
OP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,275.00 |
| Max. Negotiated Rate |
$4,413.50 |
| Rate for Payer: AlohaCare Medicaid |
$2,275.00
|
| Rate for Payer: AlohaCare Medicare |
$3,458.00
|
| Rate for Payer: Cash Price |
$2,730.00
|
| Rate for Payer: Devoted Health Medicare |
$3,822.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,458.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,185.00
|
| Rate for Payer: Health Management Network Commercial |
$3,867.50
|
| Rate for Payer: Humana Medicare |
$3,458.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,095.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,320.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,458.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,413.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,458.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,458.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,458.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,548.00
|
|
|
ARTICULAR GLENOID G203-2015-W
|
Facility
|
IP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,548.00 |
| Max. Negotiated Rate |
$4,413.50 |
| Rate for Payer: Cash Price |
$2,730.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,185.00
|
| Rate for Payer: Health Management Network Commercial |
$3,867.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,095.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,413.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,548.00
|
|
|
ASAHI SION BLACK 300CM STRT
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
|
|
ASAHI SION BLACK 300CM STRT
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: AlohaCare Medicaid |
$262.50
|
| Rate for Payer: AlohaCare Medicare |
$399.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Devoted Health Medicare |
$441.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$399.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.75
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Humana Medicare |
$399.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$399.00
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$399.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$399.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$399.00
|
| Rate for Payer: University Health Alliance Commercial |
$382.67
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 86011000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00100000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 86015000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 86011000000
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET [663]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 86015000000
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
