|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]
|
Facility
|
OP
|
$14,938.00
|
|
|
Service Code
|
HCPCS J9271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.56 |
| Max. Negotiated Rate |
$14,489.86 |
| Rate for Payer: AlohaCare Medicaid |
$7,469.00
|
| Rate for Payer: AlohaCare Medicaid |
$3,859.50
|
| Rate for Payer: AlohaCare Medicare |
$5,866.44
|
| Rate for Payer: AlohaCare Medicare |
$11,352.88
|
| Rate for Payer: Cash Price |
$8,962.80
|
| Rate for Payer: Cash Price |
$8,962.80
|
| Rate for Payer: Cash Price |
$4,631.40
|
| Rate for Payer: Cash Price |
$4,631.40
|
| Rate for Payer: Devoted Health Medicare |
$12,547.92
|
| Rate for Payer: Devoted Health Medicare |
$6,483.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$76.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$76.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,352.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,866.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$58.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,191.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,333.05
|
| Rate for Payer: Health Management Network Commercial |
$12,697.30
|
| Rate for Payer: Health Management Network Commercial |
$6,561.15
|
| Rate for Payer: Humana Medicare |
$11,352.88
|
| Rate for Payer: Humana Medicare |
$5,866.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,444.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,947.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,618.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,936.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,352.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,866.44
|
| Rate for Payer: MDX Hawaii PPO |
$14,489.86
|
| Rate for Payer: MDX Hawaii PPO |
$7,487.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,866.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,352.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,352.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,866.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,962.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,631.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,866.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,352.88
|
| Rate for Payer: University Health Alliance Commercial |
$10,888.31
|
| Rate for Payer: University Health Alliance Commercial |
$5,626.38
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| 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 |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| 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
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS J9305
|
|
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
|
|
|
PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$205.20
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$226.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$205.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Humana Medicare |
$205.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$205.20
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$205.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$205.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$162.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$205.20
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$205.20
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$226.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$205.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Humana Medicare |
$205.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$205.20
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$205.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$205.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$162.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$205.20
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
|
|
PENCIL SMOKE EVACUATION ROCKER
|
Facility
|
OP
|
$207.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: AlohaCare Medicaid |
$103.50
|
| Rate for Payer: AlohaCare Medicare |
$157.32
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Devoted Health Medicare |
$173.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$157.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$196.65
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Humana Medicare |
$157.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$157.32
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$157.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$157.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$157.32
|
| Rate for Payer: University Health Alliance Commercial |
$150.88
|
|
|
PENCIL SMOKE EVACUATION ROCKER
|
Facility
|
IP
|
$207.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$175.95 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]
|
Facility
|
IP
|
$665.00
|
|
|
Service Code
|
HCPCS J0561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$565.25 |
| Max. Negotiated Rate |
$645.05 |
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Health Management Network Commercial |
$565.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: MDX Hawaii PPO |
$645.05
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]
|
Facility
|
OP
|
$665.00
|
|
|
Service Code
|
HCPCS J0561
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.30 |
| Max. Negotiated Rate |
$645.05 |
| Rate for Payer: AlohaCare Medicaid |
$332.50
|
| Rate for Payer: AlohaCare Medicare |
$505.40
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Devoted Health Medicare |
$558.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$29.30
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$505.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$29.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$631.75
|
| Rate for Payer: Health Management Network Commercial |
$565.25
|
| Rate for Payer: Humana Medicare |
$505.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$339.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$505.40
|
| Rate for Payer: MDX Hawaii PPO |
$645.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$505.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$505.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$399.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$505.40
|
| Rate for Payer: University Health Alliance Commercial |
$484.72
|
|
|
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK [10900]
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
|
|
PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicare |
$93.48
|
| Rate for Payer: AlohaCare Medicare |
$111.72
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$103.32
|
| Rate for Payer: Devoted Health Medicare |
$123.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$93.48
|
| Rate for Payer: Humana Medicare |
$111.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.72
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.48
|
| Rate for Payer: University Health Alliance Commercial |
$89.65
|
| Rate for Payer: University Health Alliance Commercial |
$107.15
|
|
|
PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicare |
$93.48
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Devoted Health Medicare |
$103.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.85
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Humana Medicare |
$93.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.48
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.48
|
| Rate for Payer: University Health Alliance Commercial |
$89.65
|
|
|
PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicare |
$29.64
|
| Rate for Payer: AlohaCare Medicare |
$15.20
|
| Rate for Payer: AlohaCare Medicare |
$17.48
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Devoted Health Medicare |
$19.32
|
| Rate for Payer: Devoted Health Medicare |
$32.76
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Humana Medicare |
$15.20
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Humana Medicare |
$17.48
|
| Rate for Payer: Humana Medicare |
$29.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.48
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.48
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicare |
$41.80
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Devoted Health Medicare |
$46.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Humana Medicare |
$41.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.80
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.80
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicare |
$17.48
|
| Rate for Payer: AlohaCare Medicare |
$29.64
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$19.32
|
| Rate for Payer: Devoted Health Medicare |
$32.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Humana Medicare |
$17.48
|
| Rate for Payer: Humana Medicare |
$29.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.64
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.48
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
NDC 00781615395
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
|
|
PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080175
|
|
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
|
|
|
PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080175
|
|
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
|
|
