|
CAUT SURGIWAND II 5M
|
Facility
|
OP
|
$340.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$329.80 |
| Rate for Payer: AlohaCare Medicaid |
$170.00
|
| Rate for Payer: AlohaCare Medicare |
$258.40
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Devoted Health Medicare |
$285.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$258.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$323.00
|
| Rate for Payer: Health Management Network Commercial |
$289.00
|
| Rate for Payer: Humana Medicare |
$258.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$173.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$258.40
|
| Rate for Payer: MDX Hawaii PPO |
$329.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$258.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$258.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$258.40
|
| Rate for Payer: University Health Alliance Commercial |
$247.83
|
|
|
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [160202]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0689
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [160202]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0689
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$31.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$35.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$31.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.92
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.92
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [163119]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK [163119]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION [183731]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J0690
|
|
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
|
|
|
CEFAZOLIN 2 GRAM SOLUTION FOR INJECTION [183731]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| 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
|
|
|
CEFAZOLIN 3 G IN 100 ML NS - ADD-A-VIAL (SIMPLE) [4080010]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
CEFAZOLIN 3 G IN 100 ML NS - ADD-A-VIAL (SIMPLE) [4080010]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$28.88
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$28.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.88
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.88
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J0690
|
|
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
|
|
|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS J0688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$24.32
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Humana Medicare |
$24.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.32
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS J0688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
CEFAZOLIN 3 GRAM INTRAVENOUS SOLUTION [191108]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| 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 |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| 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
|
|
|
CEFAZOLIN 500 MG SOLUTION FOR INJECTION [1448]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J0690
|
|
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
|
|
|
CEFAZOLIN 500 MG SOLUTION FOR INJECTION [1448]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| 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: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| 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 Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
CEFAZOLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4301445]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CEFAZOLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4301445]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0690
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
NDC 67877054798
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
NDC 00093413664
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.70 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.80
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
NDC 67877054798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.00 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: AlohaCare Medicaid |
$64.00
|
| Rate for Payer: AlohaCare Medicare |
$97.28
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Devoted Health Medicare |
$107.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$121.60
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Humana Medicare |
$97.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.28
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.28
|
| Rate for Payer: University Health Alliance Commercial |
$93.30
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
NDC 65862021860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.00 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: AlohaCare Medicaid |
$64.00
|
| Rate for Payer: AlohaCare Medicare |
$97.28
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Devoted Health Medicare |
$107.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$121.60
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Humana Medicare |
$97.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.28
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.28
|
| Rate for Payer: University Health Alliance Commercial |
$93.30
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
NDC 00093413664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: AlohaCare Medicaid |
$51.00
|
| Rate for Payer: AlohaCare Medicare |
$77.52
|
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Devoted Health Medicare |
$85.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Humana Medicare |
$77.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$77.52
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.52
|
| Rate for Payer: University Health Alliance Commercial |
$74.35
|
|
|
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [22290]
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
NDC 65862021860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Management Network Commercial |
$108.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.20
|
| Rate for Payer: MDX Hawaii PPO |
$124.16
|
|
