|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687028265
|
|
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
|
|
|
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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687074211
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687074201
|
|
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
|
|
|
AZITHROMYCIN 250 MG TABLET [20943]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687074201
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
AZITHROMYCIN 500 MG/5ML IV (WET SOLR VIAL) [43021063]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
AZITHROMYCIN 500 MG/5ML IV (WET SOLR VIAL) [43021063]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
AZITHROMYCIN 500 MG IN 250 ML NS ADD-A-VIAL (SIMPLE) [4080012]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
AZITHROMYCIN 500 MG IN 250 ML NS ADD-A-VIAL (SIMPLE) [4080012]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$19.76
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$21.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$19.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.76
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0456
|
|
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 |
$16.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [21063]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$21.28
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$23.52
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
AZITHROMYCIN SUSPENSION (ZITHROMAX) 200 MG/5 ML (30 ML) (TAKE HOME) [4080338]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080126
|
|
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
|
|
|
AZITHROMYCIN SUSPENSION (ZITHROMAX) 200 MG/5 ML (30 ML) (TAKE HOME) [4080338]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080126
|
|
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
|
|
|
AZITHROMYCIN TABLETS (ZITHROMAX) 250 MG (TAKE HOME) [4080339]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080127
|
|
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
|
|
|
AZITHROMYCIN TABLETS (ZITHROMAX) 250 MG (TAKE HOME) [4080339]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080127
|
|
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
|
|
|
AZTREONAM 1 G/3ML IJ (WET SOLR VIAL) [4309185]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
AZTREONAM 1 G/3ML IJ (WET SOLR VIAL) [4309185]
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$106.40
|
| Rate for Payer: AlohaCare Medicare |
$82.84
|
| Rate for Payer: AlohaCare Medicare |
$41.80
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Devoted Health Medicare |
$91.56
|
| Rate for Payer: Devoted Health Medicare |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$117.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$82.84
|
| Rate for Payer: Humana Medicare |
$106.40
|
| Rate for Payer: Humana Medicare |
$41.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.80
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.80
|
| Rate for Payer: University Health Alliance Commercial |
$79.45
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
|
|
AZTREONAM 1 GRAM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080115]
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
NDC 00004080102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.05 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
|
|
AZTREONAM 1 GRAM SOLUTION FOR INJECTION [9185]
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
AZTREONAM 2 G/6ML IJ (WET SOLR VIAL) [4309186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
NDC 63323040220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 G/6ML IJ (WET SOLR VIAL) [4309186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
NDC 63323040201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS J0457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$133.86 |
| Rate for Payer: AlohaCare Medicaid |
$69.00
|
| Rate for Payer: AlohaCare Medicare |
$104.88
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Devoted Health Medicare |
$115.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$104.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.10
|
| Rate for Payer: Health Management Network Commercial |
$117.30
|
| Rate for Payer: Humana Medicare |
$104.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$104.88
|
| Rate for Payer: MDX Hawaii PPO |
$133.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$104.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$104.88
|
| Rate for Payer: University Health Alliance Commercial |
$100.59
|
|
|
AZURE XT DR AZUREXTDRMRIMEEM
|
Facility
|
IP
|
$13,452.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$7,533.12 |
| Max. Negotiated Rate |
$13,048.44 |
| Rate for Payer: Cash Price |
$8,071.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,416.40
|
| Rate for Payer: Health Management Network Commercial |
$11,434.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$12,106.80
|
| Rate for Payer: MDX Hawaii PPO |
$13,048.44
|
| Rate for Payer: University Health Alliance Commercial |
$7,533.12
|
|
|
AZURE XT DR AZUREXTDRMRIMEEM
|
Facility
|
OP
|
$13,452.00
|
|
|
Service Code
|
HCPCS C1785
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,726.00 |
| Max. Negotiated Rate |
$13,048.44 |
| Rate for Payer: AlohaCare Medicaid |
$6,726.00
|
| Rate for Payer: AlohaCare Medicare |
$10,223.52
|
| Rate for Payer: Cash Price |
$8,071.20
|
| Rate for Payer: Devoted Health Medicare |
$11,299.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,223.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,416.40
|
| Rate for Payer: Health Management Network Commercial |
$11,434.20
|
| Rate for Payer: Humana Medicare |
$10,223.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$12,106.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,860.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,223.52
|
| Rate for Payer: MDX Hawaii PPO |
$13,048.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,223.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,223.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,223.52
|
| Rate for Payer: University Health Alliance Commercial |
$7,533.12
|
|
