|
MEPILEX BORDER 3.6X4 498200
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS A6212
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
MEROPENEM 1 G/20ML IV (WET SOLR VIAL) [43017380]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
MEROPENEM 1 G/20ML IV (WET SOLR VIAL) [43017380]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
MEROPENEM 1 GRAM/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [130367]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS J2184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
MEROPENEM 1 GRAM/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [130367]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS J2184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$68.40
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$75.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$68.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.40
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION [17380]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
MEROPENEM 500 MG/10 ML IV (WET SOLR VIAL) [43017379]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
MEROPENEM 500 MG/10 ML IV (WET SOLR VIAL) [43017379]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$8.36
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$9.24
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$8.36
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
MEROPENEM 500 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [130366]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS J2184
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
MEROPENEM 500 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [130366]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS J2184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: AlohaCare Medicaid |
$31.00
|
| Rate for Payer: AlohaCare Medicare |
$47.12
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Devoted Health Medicare |
$52.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Humana Medicare |
$47.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.12
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.12
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
|
MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J2185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
MEROPENEM 500 MG INTRAVENOUS SOLUTION [17379]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J2185
|
|
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 |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
MERSILENE 5 CTX 12" DBL RS22
|
Facility
|
OP
|
$247.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$239.59 |
| Rate for Payer: AlohaCare Medicaid |
$123.50
|
| Rate for Payer: AlohaCare Medicare |
$187.72
|
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Devoted Health Medicare |
$207.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$234.65
|
| Rate for Payer: Health Management Network Commercial |
$209.95
|
| Rate for Payer: Humana Medicare |
$187.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$222.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$125.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.72
|
| Rate for Payer: MDX Hawaii PPO |
$239.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.72
|
| Rate for Payer: University Health Alliance Commercial |
$180.04
|
|
|
MERSILENE 5 CTX 12" DBL RS22
|
Facility
|
IP
|
$247.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$209.95 |
| Max. Negotiated Rate |
$239.59 |
| Rate for Payer: Cash Price |
$148.20
|
| Rate for Payer: Health Management Network Commercial |
$209.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$222.30
|
| Rate for Payer: MDX Hawaii PPO |
$239.59
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 63304017513
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 63304017513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00591224522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$25.08
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$27.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$25.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.08
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.08
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00591224522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [119913]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00093590786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$12.16
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$13.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$12.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.16
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [119913]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00093590786
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
NDC 45802009851
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: AlohaCare Medicaid |
$30.50
|
| Rate for Payer: AlohaCare Medicare |
$46.36
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Devoted Health Medicare |
$51.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Humana Medicare |
$46.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.36
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.36
|
| Rate for Payer: University Health Alliance Commercial |
$44.46
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 62559042007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
NDC 45802009851
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 62559042007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: AlohaCare Medicaid |
$31.00
|
| Rate for Payer: AlohaCare Medicare |
$47.12
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Devoted Health Medicare |
$52.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Humana Medicare |
$47.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.12
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.12
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
