|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009711
|
|
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
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009701
|
|
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
|
|
|
ATORVASTATIN 10 MG TABLET [19176]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009711
|
|
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
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009811
|
|
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
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009811
|
|
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
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009801
|
|
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
|
|
|
ATORVASTATIN 20 MG TABLET [19178]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009801
|
|
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
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009911
|
|
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
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009901
|
|
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
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084009911
|
|
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
|
|
|
ATORVASTATIN 40 MG TABLET [19177]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084009901
|
|
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
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 68084059095
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084059025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 51079021103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 51079021103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 68084059025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ATORVASTATIN 80 MG TABLET [28645]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084059095
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]
|
Facility
|
OP
|
$1,879.00
|
|
|
Service Code
|
NDC 65162069388
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$939.50 |
| Max. Negotiated Rate |
$1,822.63 |
| Rate for Payer: AlohaCare Medicaid |
$939.50
|
| Rate for Payer: AlohaCare Medicare |
$1,428.04
|
| Rate for Payer: Cash Price |
$1,127.40
|
| Rate for Payer: Devoted Health Medicare |
$1,578.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,428.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,785.05
|
| Rate for Payer: Health Management Network Commercial |
$1,597.15
|
| Rate for Payer: Humana Medicare |
$1,428.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,691.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$958.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,428.04
|
| Rate for Payer: MDX Hawaii PPO |
$1,822.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,428.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,428.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,428.04
|
| Rate for Payer: University Health Alliance Commercial |
$1,369.60
|
|
|
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [14953]
|
Facility
|
IP
|
$1,879.00
|
|
|
Service Code
|
NDC 65162069388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,597.15 |
| Max. Negotiated Rate |
$1,822.63 |
| Rate for Payer: Cash Price |
$1,127.40
|
| Rate for Payer: Health Management Network Commercial |
$1,597.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,691.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,822.63
|
|
|
ATROPINE 0.1 MG/ML INJECTION SYRINGE [137071]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J0461
|
|
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 |
$29.40
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
ATROPINE 0.1 MG/ML INJECTION SYRINGE [137071]
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J0461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: AlohaCare Medicaid |
$22.00
|
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$37.24
|
| Rate for Payer: AlohaCare Medicare |
$33.44
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Devoted Health Medicare |
$36.96
|
| Rate for Payer: Devoted Health Medicare |
$41.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Humana Medicare |
$33.44
|
| Rate for Payer: Humana Medicare |
$37.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.24
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.24
|
| Rate for Payer: University Health Alliance Commercial |
$32.07
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [177367]
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS J0461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$25.84
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Devoted Health Medicare |
$28.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Humana Medicare |
$25.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.84
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.84
|
| Rate for Payer: University Health Alliance Commercial |
$24.78
|
|
|
ATROPINE 0.4 MG/ML INTRAVENOUS SOLUTION [177367]
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J0461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
|
|
ATROPINE 1 % EYE DROPS [736]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 60219174802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$91.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Devoted Health Medicare |
$100.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$91.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.20
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.20
|
| Rate for Payer: University Health Alliance Commercial |
$87.47
|
|
|
ATROPINE 1 % EYE DROPS [736]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 60219174802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
