|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 50268043015
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 50268043011
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268043111
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68462030201
|
|
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
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268043115
|
|
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
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$619.00
|
|
|
Service Code
|
NDC 70710185207
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.50 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: AlohaCare Medicaid |
$309.50
|
| Rate for Payer: AlohaCare Medicare |
$470.44
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Devoted Health Medicare |
$519.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$470.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$588.05
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Humana Medicare |
$470.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$470.44
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$470.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$470.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$470.44
|
| Rate for Payer: University Health Alliance Commercial |
$451.19
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$619.00
|
|
|
Service Code
|
NDC 70710185206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$526.15 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.10
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$652.00
|
|
|
Service Code
|
NDC 69344010233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$326.00 |
| Max. Negotiated Rate |
$632.44 |
| Rate for Payer: AlohaCare Medicaid |
$326.00
|
| Rate for Payer: AlohaCare Medicare |
$495.52
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Devoted Health Medicare |
$547.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$495.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$619.40
|
| Rate for Payer: Health Management Network Commercial |
$554.20
|
| Rate for Payer: Humana Medicare |
$495.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$586.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$332.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$495.52
|
| Rate for Payer: MDX Hawaii PPO |
$632.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$495.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$495.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$495.52
|
| Rate for Payer: University Health Alliance Commercial |
$475.24
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$619.00
|
|
|
Service Code
|
NDC 70710185207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$526.15 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.10
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$652.00
|
|
|
Service Code
|
NDC 69344010233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$554.20 |
| Max. Negotiated Rate |
$632.44 |
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Health Management Network Commercial |
$554.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$586.80
|
| Rate for Payer: MDX Hawaii PPO |
$632.44
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$619.00
|
|
|
Service Code
|
NDC 70710185206
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.50 |
| Max. Negotiated Rate |
$600.43 |
| Rate for Payer: AlohaCare Medicaid |
$309.50
|
| Rate for Payer: AlohaCare Medicare |
$470.44
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Devoted Health Medicare |
$519.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$470.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$588.05
|
| Rate for Payer: Health Management Network Commercial |
$526.15
|
| Rate for Payer: Humana Medicare |
$470.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$557.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$470.44
|
| Rate for Payer: MDX Hawaii PPO |
$600.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$470.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$470.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$470.44
|
| Rate for Payer: University Health Alliance Commercial |
$451.19
|
|
|
INDOMETHACIN CAPSULES (INDOCIN) 50 MG (TAKE HOME) [4080369]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080157
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
INDOMETHACIN CAPSULES (INDOCIN) 50 MG (TAKE HOME) [4080369]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080157
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$13,652.35
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$13,652.35 |
| Max. Negotiated Rate |
$13,652.35 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,652.35
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 854
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 853
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$154,039.30
|
|
|
Service Code
|
MSDRG 855
|
| Min. Negotiated Rate |
$154,039.30 |
| Max. Negotiated Rate |
$154,039.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$154,039.30
|
|
|
INFILTRATION TUBING ASP-TB-TUM
|
Facility
|
IP
|
$79.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.10
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
|
|
INFILTRATION TUBING ASP-TB-TUM
|
Facility
|
OP
|
$79.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.50 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: AlohaCare Medicaid |
$39.50
|
| Rate for Payer: AlohaCare Medicare |
$60.04
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Devoted Health Medicare |
$66.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.05
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Humana Medicare |
$60.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.04
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.04
|
| Rate for Payer: University Health Alliance Commercial |
$57.58
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$13,178.31
|
|
|
Service Code
|
MSDRG 727
|
| Min. Negotiated Rate |
$13,178.31 |
| Max. Negotiated Rate |
$13,178.31 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,178.31
|
|
