|
ATROPINE 1 % EYE OINTMENT [735]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
NDC 24208082555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: AlohaCare Medicaid |
$32.50
|
| Rate for Payer: AlohaCare Medicare |
$49.40
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Devoted Health Medicare |
$54.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Humana Medicare |
$49.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.40
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.40
|
| Rate for Payer: University Health Alliance Commercial |
$47.38
|
|
|
ATROPINE 1 % EYE OINTMENT [735]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 24208082555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
AT X65 SIMPLICITY SET (BT2000)
|
Facility
|
IP
|
$424.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.40 |
| Max. Negotiated Rate |
$411.28 |
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Health Management Network Commercial |
$360.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$381.60
|
| Rate for Payer: MDX Hawaii PPO |
$411.28
|
|
|
AT X65 SIMPLICITY SET (BT2000)
|
Facility
|
OP
|
$424.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$212.00 |
| Max. Negotiated Rate |
$411.28 |
| Rate for Payer: AlohaCare Medicaid |
$212.00
|
| Rate for Payer: AlohaCare Medicare |
$322.24
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Devoted Health Medicare |
$356.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$322.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$402.80
|
| Rate for Payer: Health Management Network Commercial |
$360.40
|
| Rate for Payer: Humana Medicare |
$322.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$381.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$216.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$322.24
|
| Rate for Payer: MDX Hawaii PPO |
$411.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$322.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$322.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$322.24
|
| Rate for Payer: University Health Alliance Commercial |
$309.05
|
|
|
AUGMENT HALF BLOCK 5545-A-101
|
Facility
|
OP
|
$2,123.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,061.50 |
| Max. Negotiated Rate |
$2,059.31 |
| Rate for Payer: AlohaCare Medicaid |
$1,061.50
|
| Rate for Payer: AlohaCare Medicare |
$1,613.48
|
| Rate for Payer: Cash Price |
$1,273.80
|
| Rate for Payer: Devoted Health Medicare |
$1,783.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,613.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,486.10
|
| Rate for Payer: Health Management Network Commercial |
$1,804.55
|
| Rate for Payer: Humana Medicare |
$1,613.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,910.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,082.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,613.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,059.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,613.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,613.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,613.48
|
| Rate for Payer: University Health Alliance Commercial |
$1,188.88
|
|
|
AUGMENT HALF BLOCK 5545-A-101
|
Facility
|
IP
|
$2,123.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.88 |
| Max. Negotiated Rate |
$2,059.31 |
| Rate for Payer: Cash Price |
$1,273.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,486.10
|
| Rate for Payer: Health Management Network Commercial |
$1,804.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,910.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,059.31
|
| Rate for Payer: University Health Alliance Commercial |
$1,188.88
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$228,961.32
|
|
|
Service Code
|
MSDRG 016
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$228,961.32 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$228,961.32
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$228,961.32
|
|
|
Service Code
|
MSDRG 017
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$228,961.32 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$228,961.32
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [137797]
|
Facility
|
OP
|
$3,770.00
|
|
|
Service Code
|
HCPCS J9023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$3,656.90 |
| Rate for Payer: AlohaCare Medicaid |
$1,885.00
|
| Rate for Payer: AlohaCare Medicaid |
$4,052.00
|
| Rate for Payer: AlohaCare Medicare |
$6,159.04
|
| Rate for Payer: AlohaCare Medicare |
$2,865.20
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cash Price |
$4,862.40
|
| Rate for Payer: Cash Price |
$4,862.40
|
| Rate for Payer: Devoted Health Medicare |
$3,166.80
|
| Rate for Payer: Devoted Health Medicare |
$6,807.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$100.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$100.30
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$131.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$131.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,865.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,159.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$100.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$100.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,581.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,698.80
|
| Rate for Payer: Health Management Network Commercial |
$3,204.50
|
| Rate for Payer: Health Management Network Commercial |
$6,888.40
|
| Rate for Payer: Humana Medicare |
$2,865.20
|
| Rate for Payer: Humana Medicare |
$6,159.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,393.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,293.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,922.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,133.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,865.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,159.04
|
| Rate for Payer: MDX Hawaii PPO |
$3,656.90
|
| Rate for Payer: MDX Hawaii PPO |
$7,860.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,159.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,865.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,865.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,159.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,262.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,862.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,159.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,865.20
|
| Rate for Payer: University Health Alliance Commercial |
$2,747.95
|
| Rate for Payer: University Health Alliance Commercial |
$5,907.01
|
|
|
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION [137797]
|
Facility
|
IP
|
$3,770.00
|
|
|
Service Code
|
HCPCS J9023
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,204.50 |
| Max. Negotiated Rate |
$3,656.90 |
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cash Price |
$4,862.40
|
| Rate for Payer: Health Management Network Commercial |
$6,888.40
|
| Rate for Payer: Health Management Network Commercial |
$3,204.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,393.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,293.60
|
| Rate for Payer: MDX Hawaii PPO |
$3,656.90
|
| Rate for Payer: MDX Hawaii PPO |
$7,860.88
|
|
|
AZACITIDINE 100 MG/4ML SUBQ CHEMO IJ (WET SUSR VIAL) [4307842001]
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$787.95 |
| Max. Negotiated Rate |
$899.19 |
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$834.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
|
|
AZACITIDINE 100 MG/4ML SUBQ CHEMO IJ (WET SUSR VIAL) [4307842001]
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$104.76 |
| Rate for Payer: AlohaCare Medicaid |
$54.00
|
| Rate for Payer: AlohaCare Medicaid |
$463.50
|
| Rate for Payer: AlohaCare Medicaid |
$56.50
|
| Rate for Payer: AlohaCare Medicare |
$85.88
|
| Rate for Payer: AlohaCare Medicare |
$82.08
|
| Rate for Payer: AlohaCare Medicare |
$704.52
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Devoted Health Medicare |
$90.72
|
| Rate for Payer: Devoted Health Medicare |
$778.68
|
| Rate for Payer: Devoted Health Medicare |
$94.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$704.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$880.65
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Humana Medicare |
$82.08
|
| Rate for Payer: Humana Medicare |
$85.88
|
| Rate for Payer: Humana Medicare |
$704.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$834.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$472.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$704.52
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$704.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$704.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$556.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$704.52
|
| Rate for Payer: University Health Alliance Commercial |
$78.72
|
| Rate for Payer: University Health Alliance Commercial |
$82.37
|
| Rate for Payer: University Health Alliance Commercial |
$675.69
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$104.76 |
| Rate for Payer: AlohaCare Medicaid |
$54.00
|
| Rate for Payer: AlohaCare Medicaid |
$463.50
|
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: AlohaCare Medicare |
$82.08
|
| Rate for Payer: AlohaCare Medicare |
$704.52
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Devoted Health Medicare |
$90.72
|
| Rate for Payer: Devoted Health Medicare |
$778.68
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$704.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$880.65
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$82.08
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Humana Medicare |
$704.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$834.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$472.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$704.52
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$704.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$704.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$556.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$704.52
|
| Rate for Payer: University Health Alliance Commercial |
$78.72
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
| Rate for Payer: University Health Alliance Commercial |
$675.69
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [78420]
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$787.95 |
| Max. Negotiated Rate |
$899.19 |
| Rate for Payer: Cash Price |
$556.20
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Health Management Network Commercial |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$787.95
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$834.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.20
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: MDX Hawaii PPO |
$104.76
|
| Rate for Payer: MDX Hawaii PPO |
$899.19
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J7500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
AZATHIOPRINE 50 MG TABLET [9183]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J7500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 00093202723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: AlohaCare Medicaid |
$44.00
|
| Rate for Payer: AlohaCare Medicare |
$66.88
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Devoted Health Medicare |
$73.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Humana Medicare |
$66.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.88
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [15796]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 00093202723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 00069314019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 59762314001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 00093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 00069314019
|
|
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
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 00093202631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: AlohaCare Medicaid |
$44.00
|
| Rate for Payer: AlohaCare Medicare |
$66.88
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Devoted Health Medicare |
$73.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Humana Medicare |
$66.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.88
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [15797]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 59762314001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: AlohaCare Medicaid |
$44.00
|
| Rate for Payer: AlohaCare Medicare |
$66.88
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Devoted Health Medicare |
$73.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Humana Medicare |
$66.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.88
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.88
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687074211
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
