|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9487]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [9489]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
CEFTRIAXONE 2 GM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080093]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 00004080032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
CEFTRIAXONE 2 GM IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080093]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 00004080032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [9493]
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.10
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
|
|
CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [9493]
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: AlohaCare Medicaid |
$39.50
|
| Rate for Payer: AlohaCare Medicare |
$60.04
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Devoted Health Medicare |
$66.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.05
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Humana Medicare |
$60.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.04
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.04
|
| Rate for Payer: University Health Alliance Commercial |
$57.58
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [9488]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [9490]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
CEFTRIAXONE SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4309487]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
CEFTRIAXONE SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4309487]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
CEFTRIAXONE SODIUM 250 MG/2.5ML IJ (WET SOLR VIAL) [4309489]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
CEFTRIAXONE SODIUM 250 MG/2.5ML IJ (WET SOLR VIAL) [4309489]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
CEFTRIAXONE SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [4309490]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$9.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
CEFTRIAXONE SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [4309490]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 67877021560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$15.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$15.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 65862069920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$12.16
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$13.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$12.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.16
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 67877021560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
CEFUROXIME AXETIL 250 MG TABLET [9495]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 65862069920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CEFUROXIME AXETIL 500 MG TABLET [9496]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 65862070020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
CEFUROXIME AXETIL 500 MG TABLET [9496]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 65862070020
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
CEFUROXIME SODIUM 750 MG/8.3 ML IJ (WET SOLR VIAL) [4301465]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
