|
CEFEPIME HCL 2 G/20ML IV (WET SOLR VIAL) [43027311]
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS J0692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: AlohaCare Medicaid |
$50.50
|
| Rate for Payer: AlohaCare Medicare |
$76.76
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Devoted Health Medicare |
$84.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.95
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.76
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$60.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.76
|
| Rate for Payer: University Health Alliance Commercial |
$73.62
|
|
|
CEFOXITIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080121]
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: AlohaCare Medicaid |
$22.00
|
| Rate for Payer: AlohaCare Medicare |
$33.44
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Devoted Health Medicare |
$36.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.80
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Humana Medicare |
$33.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.44
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.44
|
| Rate for Payer: University Health Alliance Commercial |
$32.07
|
|
|
CEFOXITIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080121]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [9463]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
CEFOXITIN SODIUM 2 G/20ML IV (WET SOLR VIAL) [4309463]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
CEFOXITIN SODIUM 2 G/20ML IV (WET SOLR VIAL) [4309463]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
CEFTAROLINE FOSAMIL 400 MG/20ML IV (WET SOLR VIAL) [430107670]
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: AlohaCare Medicaid |
$232.00
|
| Rate for Payer: AlohaCare Medicare |
$352.64
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Devoted Health Medicare |
$389.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$352.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$440.80
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Humana Medicare |
$352.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$352.64
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$352.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$352.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$278.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$352.64
|
| Rate for Payer: University Health Alliance Commercial |
$338.21
|
|
|
CEFTAROLINE FOSAMIL 400 MG/20ML IV (WET SOLR VIAL) [430107670]
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.40 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
|
|
CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.40 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
|
|
CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION [107670]
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: AlohaCare Medicaid |
$232.00
|
| Rate for Payer: AlohaCare Medicare |
$352.64
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Devoted Health Medicare |
$389.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$352.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$440.80
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Humana Medicare |
$352.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$352.64
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$352.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$352.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$278.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$352.64
|
| Rate for Payer: University Health Alliance Commercial |
$338.21
|
|
|
CEFTAROLINE FOSAMIL 600 MG/20ML IV (WET SOLR VIAL) [430107671]
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: AlohaCare Medicaid |
$232.00
|
| Rate for Payer: AlohaCare Medicare |
$352.64
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Devoted Health Medicare |
$389.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$352.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$440.80
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Humana Medicare |
$352.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$352.64
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$352.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$352.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$278.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$352.64
|
| Rate for Payer: University Health Alliance Commercial |
$338.21
|
|
|
CEFTAROLINE FOSAMIL 600 MG/20ML IV (WET SOLR VIAL) [430107671]
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.40 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
|
|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$394.40 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
|
|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION [107671]
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
HCPCS J0712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$450.08 |
| Rate for Payer: AlohaCare Medicaid |
$232.00
|
| Rate for Payer: AlohaCare Medicare |
$352.64
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Devoted Health Medicare |
$389.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.24
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$352.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$440.80
|
| Rate for Payer: Health Management Network Commercial |
$394.40
|
| Rate for Payer: Humana Medicare |
$352.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$417.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$236.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$352.64
|
| Rate for Payer: MDX Hawaii PPO |
$450.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$352.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$352.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$278.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$352.64
|
| Rate for Payer: University Health Alliance Commercial |
$338.21
|
|
|
CEFTAZIDIME 1 G/10ML IJ (WET SOLR VIAL) [4309474]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
CEFTAZIDIME 1 G/10ML IJ (WET SOLR VIAL) [4309474]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION [9474]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 G/12ML IV (WET SOLR VIAL) [430128163]
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
HCPCS J0714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.95 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: AlohaCare Medicaid |
$141.00
|
| Rate for Payer: AlohaCare Medicaid |
$374.00
|
| Rate for Payer: AlohaCare Medicare |
$568.48
|
| Rate for Payer: AlohaCare Medicare |
$214.32
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Devoted Health Medicare |
$236.88
|
| Rate for Payer: Devoted Health Medicare |
$628.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.94
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$214.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$568.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$267.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.60
|
| Rate for Payer: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Health Management Network Commercial |
$635.80
|
| Rate for Payer: Humana Medicare |
$214.32
|
| Rate for Payer: Humana Medicare |
$568.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$673.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$143.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$381.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$214.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$568.48
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
| Rate for Payer: MDX Hawaii PPO |
$725.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$568.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$214.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$214.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$568.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$169.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$448.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$568.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$214.32
|
| Rate for Payer: University Health Alliance Commercial |
$205.55
|
| Rate for Payer: University Health Alliance Commercial |
$545.22
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 G/12ML IV (WET SOLR VIAL) [430128163]
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
HCPCS J0714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.70 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Health Management Network Commercial |
$635.80
|
| Rate for Payer: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$673.20
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
| Rate for Payer: MDX Hawaii PPO |
$725.56
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [128163]
|
Facility
|
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J0714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.95 |
| Max. Negotiated Rate |
$725.56 |
| Rate for Payer: AlohaCare Medicaid |
$374.00
|
| Rate for Payer: AlohaCare Medicare |
$568.48
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Devoted Health Medicare |
$628.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$568.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$710.60
|
| Rate for Payer: Health Management Network Commercial |
$635.80
|
| Rate for Payer: Humana Medicare |
$568.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$673.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$381.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$568.48
|
| Rate for Payer: MDX Hawaii PPO |
$725.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$568.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$568.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$448.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$568.48
|
| Rate for Payer: University Health Alliance Commercial |
$545.22
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION [128163]
|
Facility
|
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J0714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$635.80 |
| Max. Negotiated Rate |
$725.56 |
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Health Management Network Commercial |
$635.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$673.20
|
| Rate for Payer: MDX Hawaii PPO |
$725.56
|
|
|
CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [9492]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [9492]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$45.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Humana Medicare |
$45.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.60
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
