|
XENOSURE BIOLOGIC PATCH 1.5X14
|
Facility
|
IP
|
$1,190.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$666.40 |
| Max. Negotiated Rate |
$1,154.30 |
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$833.00
|
| Rate for Payer: Health Management Network Commercial |
$1,011.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,071.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,154.30
|
| Rate for Payer: University Health Alliance Commercial |
$666.40
|
|
|
XENOSURE BIOLOGIC PATCH 1.5X14
|
Facility
|
OP
|
$1,190.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.00 |
| Max. Negotiated Rate |
$1,154.30 |
| Rate for Payer: AlohaCare Medicaid |
$595.00
|
| Rate for Payer: AlohaCare Medicare |
$904.40
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Devoted Health Medicare |
$999.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$904.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$833.00
|
| Rate for Payer: Health Management Network Commercial |
$1,011.50
|
| Rate for Payer: Humana Medicare |
$904.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,071.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$606.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$904.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,154.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$904.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$904.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$904.40
|
| Rate for Payer: University Health Alliance Commercial |
$666.40
|
|
|
XENOSURE BIOLOGIC VAS PATCH
|
Facility
|
IP
|
$859.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$481.04 |
| Max. Negotiated Rate |
$833.23 |
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$601.30
|
| Rate for Payer: Health Management Network Commercial |
$730.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$773.10
|
| Rate for Payer: MDX Hawaii PPO |
$833.23
|
| Rate for Payer: University Health Alliance Commercial |
$481.04
|
|
|
XENOSURE BIOLOGIC VAS PATCH
|
Facility
|
OP
|
$859.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$429.50 |
| Max. Negotiated Rate |
$833.23 |
| Rate for Payer: AlohaCare Medicaid |
$429.50
|
| Rate for Payer: AlohaCare Medicare |
$652.84
|
| Rate for Payer: Cash Price |
$515.40
|
| Rate for Payer: Devoted Health Medicare |
$721.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$652.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$601.30
|
| Rate for Payer: Health Management Network Commercial |
$730.15
|
| Rate for Payer: Humana Medicare |
$652.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$773.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$438.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$652.84
|
| Rate for Payer: MDX Hawaii PPO |
$833.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$652.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$652.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$652.84
|
| Rate for Payer: University Health Alliance Commercial |
$481.04
|
|
|
XXL ESOPHAGEAL 18X4X75
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$723.35 |
| Max. Negotiated Rate |
$825.47 |
| Rate for Payer: Cash Price |
$510.60
|
| Rate for Payer: Health Management Network Commercial |
$723.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$765.90
|
| Rate for Payer: MDX Hawaii PPO |
$825.47
|
|
|
XXL ESOPHAGEAL 18X4X75
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$425.50 |
| Max. Negotiated Rate |
$825.47 |
| Rate for Payer: AlohaCare Medicaid |
$425.50
|
| Rate for Payer: AlohaCare Medicare |
$646.76
|
| Rate for Payer: Cash Price |
$510.60
|
| Rate for Payer: Devoted Health Medicare |
$714.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$646.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$808.45
|
| Rate for Payer: Health Management Network Commercial |
$723.35
|
| Rate for Payer: Humana Medicare |
$646.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$765.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$646.76
|
| Rate for Payer: MDX Hawaii PPO |
$825.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$646.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$646.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$646.76
|
| Rate for Payer: University Health Alliance Commercial |
$620.29
|
|
|
Y-ADAPTER NS SGL 5920-000-304
|
Facility
|
OP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$100.32
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.32
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.32
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
Y-ADAPTER NS SGL 5920-000-304
|
Facility
|
IP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
|
YOUNGSWICK 1MM ACCUCUT 19506
|
Facility
|
IP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$398.65 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
|
|
YOUNGSWICK 1MM ACCUCUT 19506
|
Facility
|
OP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: AlohaCare Medicaid |
$234.50
|
| Rate for Payer: AlohaCare Medicare |
$356.44
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Devoted Health Medicare |
$393.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$445.55
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Humana Medicare |
$356.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$239.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.44
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.44
|
| Rate for Payer: University Health Alliance Commercial |
$341.85
|
|
|
YOUNGSWICK 2MM ACCUCUT 19507
|
Facility
|
IP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$398.65 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
|
|
YOUNGSWICK 2MM ACCUCUT 19507
|
Facility
|
OP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: AlohaCare Medicaid |
$234.50
|
| Rate for Payer: AlohaCare Medicare |
$356.44
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Devoted Health Medicare |
$393.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$445.55
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Humana Medicare |
$356.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$239.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.44
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.44
|
| Rate for Payer: University Health Alliance Commercial |
$341.85
|
|
|
YOUNGSWICK 3MM ACCUCUT 19508
|
Facility
|
OP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: AlohaCare Medicaid |
$234.50
|
| Rate for Payer: AlohaCare Medicare |
$356.44
|
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Devoted Health Medicare |
$393.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$445.55
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Humana Medicare |
$356.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$239.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.44
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.44
|
| Rate for Payer: University Health Alliance Commercial |
$341.85
|
|
|
YOUNGSWICK 3MM ACCUCUT 19508
|
Facility
|
IP
|
$469.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$398.65 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
|
|
YTTRIUM-90 THERASPHERE [4080084]
|
Facility
|
IP
|
$31,373.00
|
|
|
Service Code
|
HCPCS C2616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26,667.05 |
| Max. Negotiated Rate |
$30,431.81 |
| Rate for Payer: Cash Price |
$18,823.80
|
| Rate for Payer: Cash Price |
$15,736.20
|
| Rate for Payer: Health Management Network Commercial |
$22,292.95
|
| Rate for Payer: Health Management Network Commercial |
$26,667.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,604.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$28,235.70
|
| Rate for Payer: MDX Hawaii PPO |
$25,440.19
|
| Rate for Payer: MDX Hawaii PPO |
$30,431.81
|
|
|
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION [11691]
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J3485
|
|
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 |
$24.00
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION [11691]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS J3485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicare |
$93.48
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: AlohaCare Medicare |
$82.84
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Devoted Health Medicare |
$103.32
|
| Rate for Payer: Devoted Health Medicare |
$91.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Humana Medicare |
$82.84
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Humana Medicare |
$93.48
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.48
|
| Rate for Payer: University Health Alliance Commercial |
$79.45
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
| Rate for Payer: University Health Alliance Commercial |
$89.65
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
NDC 65862004824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.50 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: AlohaCare Medicaid |
$56.50
|
| Rate for Payer: AlohaCare Medicare |
$85.88
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Devoted Health Medicare |
$94.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Humana Medicare |
$85.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.88
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.88
|
| Rate for Payer: University Health Alliance Commercial |
$82.37
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
NDC 49702021248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 65862004824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
|
ZIDOVUDINE 10 MG/ML ORAL SYRUP [11693]
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
NDC 49702021248
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: AlohaCare Medicaid |
$78.00
|
| Rate for Payer: AlohaCare Medicare |
$118.56
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$131.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.20
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Humana Medicare |
$118.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.56
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.56
|
| Rate for Payer: University Health Alliance Commercial |
$113.71
|
|
|
ZINC OXIDE 20 % TOPICAL OINTMENT [8874]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00536131628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
ZINC OXIDE 20 % TOPICAL OINTMENT [8874]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00536131628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE [111153]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 74300000071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE [111153]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 74300000071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
